uiselect actives - university human resources

C O V E R A G E M A N U A L

UISELECT Actives

NOTICE This group health plan is sponsored and funded by the University of Iowa. The University of

Iowa has a financial arrangement with Wellmark under which the University of Iowa is solely

responsible for claim payment amounts for covered services provided to you. Wellmark provides

administrative services and provider network access only and does not assume any financial risk

or obligation for claim payment amounts.

Form Number: Wellmark IA Grp

Form Number: Wellmark IA Grp UISelect AC400 Version 01/20

Group Effective Date: 1/1/2021

Plan Year: January 1

Print Date: 2/18/2021

– Coverage Code: WEB T94

Version: 01/21

Wellmark.com

Contents

About This Coverage Manual ....................................................................... 1

1. What You Pay .................................................................................... 3 Payment Summary ........................................................................................................................... 4 Payment Details ............................................................................................................................... 6

2. At a Glance - Covered and Not Covered ............................................ 13 Medical ........................................................................................................................................... 13 Prescription Drugs .......................................................................................................................... 16

3. Details - Covered and Not Covered .................................................... 17 Medical ........................................................................................................................................... 17 Prescription Drugs .......................................................................................................................... 34

4. General Conditions of Coverage, Exclusions, and Limitations .......... 39 Conditions of Coverage.................................................................................................................. 39 General Exclusions ........................................................................................................................ 40 Benefit Limitations .......................................................................................................................... 42

5. Choosing a Provider ......................................................................... 45 Medical ........................................................................................................................................... 45 Prescription Drugs .......................................................................................................................... 51

6. Notification Requirements and Care Coordination .......................... 53 Medical ........................................................................................................................................... 53 Prescription Drugs .......................................................................................................................... 57

7. Factors Affecting What You Pay ....................................................... 59 Medical ........................................................................................................................................... 59 Prescription Drugs .......................................................................................................................... 63

8. Coverage Eligibility and Effective Date ............................................. 67 Eligible Members ............................................................................................................................ 67 When Coverage Begins ................................................................................................................. 67 Late Enrollees ................................................................................................................................ 67 Changes to Information Related to You or to Your Benefits .......................................................... 68 Qualified Medical Child Support Order .......................................................................................... 68

9. Coverage Changes and Termination .................................................. 71 Coverage Change Events .............................................................................................................. 71 Requirement to Notify Group Sponsor ........................................................................................... 72 Coverage Termination.................................................................................................................... 72 Coverage Continuation .................................................................................................................. 73

10. Claims.............................................................................................. 77 When to File a Claim ...................................................................................................................... 77 How to File a Claim ........................................................................................................................ 77 Notification of Decision................................................................................................................... 78

11. Coordination of Benefits .................................................................. 81 Other Coverage .............................................................................................................................. 81 Claim Filing .................................................................................................................................... 81 Rules of Coordination ..................................................................................................................... 82 Coordination with Medicare ........................................................................................................... 85

12. Appeals ............................................................................................ 87 Right of Appeal ............................................................................................................................... 87 How to Request an Internal Appeal ............................................................................................... 87 Where to Send Internal Appeal ...................................................................................................... 87 Review of Internal Appeal .............................................................................................................. 87 Decision on Internal Appeal ........................................................................................................... 88 External Review ............................................................................................................................. 88 Arbitration and Legal Action ........................................................................................................... 89

13. Arbitration and Legal Action ............................................................ 91 Mandatory Arbitration ..................................................................................................................... 91 Covered Claims .............................................................................................................................. 91 No Class Arbitrations and Class Actions Waiver ........................................................................... 91 Claims Excluded from Mandatory Arbitration ................................................................................ 91 Arbitration Process Generally ........................................................................................................ 92 Arbitration Fees and Other Costs .................................................................................................. 93 Confidentiality ................................................................................................................................. 93 Questions of Arbitrability ................................................................................................................ 93 Claims Excluded By Applicable Law .............................................................................................. 93 Survival and Severability of Terms ................................................................................................ 93

14. General Provisions .......................................................................... 95 Contract .......................................................................................................................................... 95 Interpreting this Coverage Manual ................................................................................................. 95 Plan Year ....................................................................................................................................... 95 Authority to Terminate, Amend, or Modify ..................................................................................... 95 Authorized Group Benefits Plan Changes ..................................................................................... 95 Member Participation ..................................................................................................................... 95 Authorized Representative ............................................................................................................. 95 Release of Information ................................................................................................................... 96 Privacy of Information .................................................................................................................... 96 Member Health Support Services .................................................................................................. 97 Value Added or Innovative Benefits ............................................................................................... 97 Value-Based Programs .................................................................................................................. 97 Health Insurance Portability and Accountability Act of 1996 ......................................................... 97 Nonassignment .............................................................................................................................. 99 Governing Law ............................................................................................................................. 100 Medicaid Enrollment and Payments to Medicaid ......................................................................... 100 Subrogation .................................................................................................................................. 100 Workers’ Compensation ............................................................................................................... 102 Payment in Error .......................................................................................................................... 103 Notice ........................................................................................................................................... 103 Inspection of Coverage ................................................................................................................ 103 Submitting a Complaint ................................................................................................................ 103 Consent to Telephone Calls and Text or Email Notifications....................................................... 103

Glossary .................................................................................................. 105

Index ...................................................................................................... 109

Form Number: Wellmark IA Grp/AM_ 0121 1 WEB T94

About This Coverage Manual

Contract This coverage manual describes your rights and responsibilities under your group health plan.

You and your covered dependents have the right to request a copy of this coverage manual, at no

cost to you, by contacting the University of Iowa.

Please note: The University of Iowa has the authority to terminate, amend, or modify the

coverage described in this coverage manual at any time. Any amendment or modification will be

in writing and will be as binding as this coverage manual. If your contract is terminated, you

may not receive benefits.

You should familiarize yourself with the entire manual because it describes your benefits,

payment obligations, provider networks, claim processes, and other rights and responsibilities.

This group health plan consists of medical benefits and prescription drug benefits. Your

Wellmark Health Plan of Iowa, Inc., (Wellmark) benefits are called Blue Access. The

prescription drug benefits are called Blue Rx Value Plus. This coverage manual will indicate

when the service, supply or drug is considered medical benefits or drug benefits by using

sections, headings, and notes when necessary.

Charts Some sections have charts, which provide a quick reference or summary but are not a complete

description of all details about a topic. A particular chart may not describe some significant

factors that would help determine your coverage, payments, or other responsibilities. It is

important for you to look up details and not to rely only upon a chart. It is also important to

follow any references to other parts of the manual. (References tell you to “see” a section or

subject heading, such as, “See Details – Covered and Not Covered.” References may also include

a page number.)

Complete Information Very often, complete information on a subject requires you to consult more than one section of

the manual. For instance, most information on coverage will be found in these sections:

◼ At a Glance – Covered and Not Covered

◼ Details – Covered and Not Covered

◼ General Conditions of Coverage, Exclusions, and Limitations

However, coverage might be affected also by your choice of provider (information in the

Choosing a Provider section), certain notification requirements if applicable to your group

health plan (the Notification Requirements and Care Coordination section), and considerations

of eligibility (the Coverage Eligibility and Effective Date section).

Even if a service is listed as covered, benefits might not be available in certain situations, and

even if a service is not specifically described as being excluded, it might not be covered.

Read Thoroughly You can use your group health plan to the best advantage by learning how this document is

organized and how sections are related to each other. And whenever you look up a particular

topic, follow any references, and read thoroughly.

About This Coverage Manual

WEB T94 2 Form Number: Wellmark IA Grp/AM_ 0121

Your coverage includes many services, treatments, supplies, devices, and drugs. Throughout the

coverage manual, the words services or supplies refer to any services, treatments, supplies,

devices, or drugs, as applicable in the context, that may be used to diagnose or treat a condition.

Questions If you have questions about your group health plan, or are unsure whether a particular service or

supply is covered, call the Customer Service number on your ID card.

Form Number: Wellmark IA Grp/WYP_ 0121 3 WEB T94

1. What You Pay

This section is intended to provide you with an overview of your payment obligations under this

group health plan. This section is not intended to be and does not constitute a complete

description of your payment obligations. To understand your complete payment obligations you

must become familiar with this entire coverage manual, especially the Factors Affecting What

You Pay and Choosing a Provider sections.

Provider Network Under the medical benefits of this plan, your network of providers consists of domestic

providers and Wellmark Blue HMOSM Providers. All other providers are not in your network.

Which provider type you choose will affect what you pay.

Generally, you are only covered for services received from Wellmark Blue HMO Providers;

however, you may be covered for services received from Participating Providers only in the case

of an emergency, accidental injury, guest membership, or approved referrals. You may be

covered for services received from Out-of-Network Providers in the case of an emergency,

accidental injury, or approved Out-of-Network referrals.

Wellmark Blue HMO Providers. These providers participate with the Wellmark Blue HMO

network. Throughout this coverage manual we will refer to these providers as “Network”

Providers. Benefits for most covered services are available only when received from Wellmark

Blue HMO Providers.

Participating Providers. These providers participate with a Blue Cross and/or Blue Shield

Plan, but not with the Wellmark Blue HMO network. Generally, you are only covered for

services received from Participating Providers in case of emergency, accidental injury, guest

membership, or approved referrals.

Out-of-Network Providers. Out-of-Network Providers do not participate with the Wellmark

Blue HMO network or any other Blue Cross and/or Blue Shield Plan. Generally, you are only

covered for services received from Out-of-Network Providers in case of emergency, accidental

injury, or approved Out-of-Network referrals.

Medical

Provider Types Which provider type you choose will affect what you pay.

Domestic Providers. Domestic providers participate directly with your employer’s domestic

provider network and also participate with the Wellmark Blue HMO network. These are

Network providers who participate with UI Health Care, University of Iowa Hospitals and

Clinics, The Iowa Clinic, and the Washington County Hospital and Clinics. You typically pay the

least for services received from these providers.

Network Providers. Network providers participate with the Wellmark Blue HMO network,

but not with your employer’s domestic provider network. You typically pay more for services

from these providers than for services from domestic providers.

What You Pay

WEB T94 4 Form Number: Wellmark IA Grp/WYP_ 0121

Payment Summary This chart summarizes your payment responsibilities. It is only intended to provide you with an

overview of your payment obligations. It is important that you read this entire section and not

just rely on this chart for your payment obligations.

You Pay

Deductible

Domestic Providers

$400 per person for covered services and for covered mental health and chemical dependency services.

$800 (maximum) per family* for covered services and covered mental health and chemical dependency services.

Network Providers

$800 per person $1,600 (maximum) per family*

Emergency Room Copayment

$100

Office Visit Copayment

Domestic Providers

$10 for: ◼ covered services received from primary care providers ◼ covered services received from chiropractors ◼ covered services received from occupational therapists ◼ covered services received from physical therapists ◼ covered services received from speech pathologists ◼ covered mental health and chemical dependency treatment received in an office

setting

$20 for covered services received from non-primary care providers.

Network Providers $10 for covered mental health and chemical dependency treatment received in an office setting. $35 for: ◼ covered services received from primary care providers ◼ covered services received from chiropractors ◼ covered services received from occupational therapists ◼ covered services received from physical therapists ◼ covered services received from speech pathologists $50 for covered services received from non-primary care providers. UI Quick Care Clinic $5

What You Pay


You Pay

Telehealth Services Copayment

Domestic Providers

$10 for: ◼ covered telehealth services received from primary care practitioners ◼ covered telehealth services received from chiropractors ◼ covered telehealth services received from occupational therapists ◼ covered telehealth services received from physical therapists ◼ covered telehealth services received from speech pathologists ◼ covered telehealth mental health and chemical dependency treatment

$20 for covered telehealth services received from non-primary care practitioners.

Network Providers $10 for covered telehealth mental health and chemical dependency treatment. $35 for: ◼ covered telehealth services received from primary care practitioners ◼ covered telehealth services received from chiropractors ◼ covered telehealth services received from occupational therapists ◼ covered telehealth services received from physical therapists ◼ covered telehealth services received from speech pathologists $50 for covered telehealth services received from non-primary care practitioners. UI Quick Care Clinic $5

Urgent Care Center Copayment

Domestic Providers

$10 for covered services received in Iowa classified by Wellmark as Urgent Care Centers.†

Network Providers $10 for covered treatment of mental health conditions and chemical dependency when received from providers in Iowa classified by Wellmark as Urgent Care Centers.† $35 for all other covered services received in Iowa classified by Wellmark as Urgent Care Centers.†

Coinsurance

Domestic Providers

10% for covered emergency room services.

15% for all other covered services received from domestic providers.

Network Providers

10% for covered emergency room services.

15% for covered inpatient and outpatient treatment of mental health conditions and chemical dependency.

25% for all other covered services received from Network Providers.

Out-of-Pocket Maximum

Domestic Providers

$2,000 per person

$3,400 (maximum) per family*

Network Providers $3,000 per person $6,000 (maximum) per family*

*Family amounts are reached from amounts accumulated on behalf of any combination of covered family members. A member will not be required to satisfy more than the single deductible before we make benefit payments for that member. †For a list of Iowa facilities classified by Wellmark as Urgent Care Centers, please see the Wellmark Provider Directory.

What You Pay


Prescription Drugs

You Pay†

Coinsurance

0% for Tier 1 medications. 30% for Tier 2 medications and glucometers. 50% for Tier 3 medications. For more information see Tiers, page 63. 15% for pharmacy durable medical equipment devices received from participating pharmacies. 25% for pharmacy durable medical equipment devices received from nonparticipating pharmacies.

Out-of-Pocket Maximum

$1,100 per person $2,200 (maximum) per family*

*Family amounts are reached from amounts accumulated on behalf of any combination of covered family members. †You pay the entire cost if you purchase a drug or pharmacy durable medical equipment device that is not on the Wellmark Blue Rx Value Plus Drug List. See Wellmark Blue Rx Value Plus Drug List, page 34.

Prescription Maximums Generally, there is a maximum days' supply of medication you may receive in a single

prescription. However, exceptions may be made for certain prescriptions packaged in a dose

exceeding the maximum days' supply covered under your Blue Rx Value Plus prescription drug

benefits. To determine if this exception applies to your prescription, call the Customer Service

number on your ID card.

Your payment obligations may be determined by the quantity of medication you purchase.

Prescription Maximum

100 day retail

100 day mail order

30 day specialty

180 days for oral contraceptives, estrogen, and amoxicillin

365 days for Retin-A (tretinion)

Payment Details

Medical

Deductible This is a fixed dollar amount you pay for

covered services in a benefit year before

medical benefits become available.

The family deductible amount is reached

from amounts accumulated on behalf of any

combination of covered family members.

A member will not be required to satisfy

more than the single deductible before we

make benefit payments for that member.

Once you meet the deductible, then

coinsurance applies.

Deductible amounts are waived for some

services. See Waived Payment Obligations

later in this section.

Copayment This is a fixed dollar amount that you pay

each time you receive certain covered

services.

What You Pay


Emergency Room Copayment.

The emergency room copayment:

◼ applies to emergency room services.

◼ is taken once per visit.

◼ is waived if you are admitted as an

inpatient of a facility immediately

following emergency room services.

Office Visit Copayment.

The office visit copayment:

◼ applies to covered office services

received from domestic practitioners

and Network practitioners or from the

UI Quick Care Clinic.

◼ is taken once per practitioner per date of

service.

Please note: For purposes of determining

your copayment responsibility, Network

Providers are classified by Wellmark as

either primary care providers or non-

primary care providers. To determine

whether the primary care provider

copayment or the non-primary care

provider copayment applies, you should call

the Customer Service number on your ID

card before receiving any services to

determine whether your provider is

classified by Wellmark as a primary care

provider or a non-primary care provider for

purposes of your copayment responsibility.

How providers are classified in the

Wellmark Provider Directory does not

determine whether a provider is a primary

care provider or a non-primary care

provider for purposes of your copayment

responsibility. For example, a provider

might be listed under multiple specialties in

the provider directory, such as internal

medicine and oncology, but would be



responsibility.

A primary care provider is a Network:

◼ advanced registered nurse practitioner

(ARNP)

◼ family practitioner

◼ general practitioner

◼ internal medicine practitioner

◼ obstetrician/gynecologist

◼ pediatrician

◼ physician assistant (PA)

All other Network Providers are non-

primary care providers. See Choosing a

Provider, page 45.

Telehealth Services Copayment.

The telehealth services copayment:

◼ applies to covered telehealth services

received from domestic practitioners

and Network practitioners or from the

UI Quick Care Clinic.

◼ is taken once per practitioner per date of

service.

Please note: For purposes of determining

your copayment responsibility, Network

Providers are classified by Wellmark as

either primary care providers or non-

primary care providers. To determine

whether the primary care provider

copayment or the non-primary care

provider copayment applies, you should call

the Customer Service number on your ID

card before receiving any services to

determine whether your provider is


provider or a non-primary care provider for

purposes of your copayment responsibility.

How providers are classified in the

Wellmark Provider Directory does not

determine whether a provider is a primary

care provider or a non-primary care


responsibility. For example, a provider

might be listed under multiple specialties in

the provider directory, such as internal

medicine and oncology, but would be



responsibility.

A primary care provider is a Network:

◼ advanced registered nurse practitioner

(ARNP)

◼ family practitioner

◼ general practitioner

What You Pay


◼ internal medicine practitioner

◼ obstetrician/gynecologist

◼ pediatrician

◼ physician assistant (PA)

All other Network Providers are non-

primary care providers. See Choosing a

Provider, page 45.

Urgent Care Center Copayment.

The urgent care center copayment:

◼ applies to covered urgent care services

received from:

⎯ domestic and Network Providers in

Iowa classified by Wellmark as

Urgent Care Centers.

◼ is taken once per provider per date of

service.

Please note: If you receive care at a facility

in Iowa that is not classified by Wellmark as

an Urgent Care Center, you may be

responsible for your deductible and

coinsurance (as applicable) instead of the

urgent care center copayment. Therefore,

before receiving any urgent care services,

you should determine if the facility is

classified by Wellmark as an Urgent Care

Center. See the Wellmark Provider

Directory at Wellmark.com or call the

Customer Service number on your ID card

to determine whether a facility is classified

by Wellmark as an Urgent Care Center.

Copayment amount(s) are waived for some



Coinsurance Coinsurance is an amount you pay for

certain covered services. Coinsurance is

calculated by multiplying the fixed

percentage(s) shown earlier in this section

times Wellmark’s payment arrangement

amount. Payment arrangements may differ

depending on the contracting status of the

provider and/or the state where you receive

services. For details, see How Coinsurance

is Calculated, page 59. Coinsurance

amounts apply after you meet the

deductible and any applicable copayments.

Coinsurance amounts are waived for some



Out-of-Pocket Maximum The out-of-pocket maximum is the

maximum amount you pay, out of your

pocket, for most covered services in a

benefit year. Many amounts you pay for

covered services during a benefit year

accumulate toward the out-of-pocket

maximum. These amounts include:

◼ Deductible.

◼ Coinsurance.

◼ Emergency room copayments.

◼ Office visit copayments.

◼ Telehealth services copayments.

◼ Urgent care center copayments.

The family out-of-pocket maximum is

reached from applicable amounts paid on

behalf of any combination of covered family

members.


more than the single out-of-pocket

maximum.

However, certain amounts do not apply

toward your out-of-pocket maximum.

◼ Amounts representing any general

exclusions and conditions. See General

Conditions of Coverage, Exclusions, and

Limitations, page 39.

◼ Difference in cost between the provider’s

amount charged and our maximum

allowable fee when you receive services

from an Out-of-Network Provider.

◼ Difference in cost between the generic

drug and the brand name drug when

you purchase a brand name drug that

has an FDA-approved “A”-rated

medically appropriate generic

equivalent.

These amounts continue even after you have

met your out-of-pocket maximum.

What You Pay


Benefits Maximums Benefits maximums are the maximum

benefit amounts that each member is

eligible to receive.

Benefits maximums that apply per benefit

year or per lifetime are reached from

benefits accumulated under this group

health plan and any prior group health

plans sponsored by the University of Iowa

and administered by Wellmark Health Plan

of Iowa, Inc.

Waived Payment Obligations Some payment obligations are waived for the following covered services.

Covered Service Payment Obligation Waived

Breast pumps (manual or non-hospital grade electric) purchased from

a covered home/durable medical equipment provider.

Deductible

Coinsurance

Copayment

Breastfeeding support, supplies, and one-on-one lactation consultant

services, including counseling and education, during pregnancy and/or

the duration of breastfeeding.

Deductible

Coinsurance

Copayment

Contraceptive medical devices, such as intrauterine devices and

diaphragms.

Deductible

Coinsurance

Copayment

Hearing examination (routine). Deductible

Coinsurance

Copayment

Implanted and injected contraceptives. Deductible

Coinsurance

Copayment

Independent laboratory services. Deductible

Copayment

Interprofessional telephone, Internet, and electronic health record

referrals, assessments, and management services provided by the

treating, requesting, or consultive provider on behalf of an active

member received from domestic providers.

Deductible

Coinsurance

Copayment

Medical evaluations and counseling for nicotine dependence per U.S.

Preventive Services Task Force (USPSTF) guidelines.

Deductible

Coinsurance

Copayment

Newborn’s initial hospitalization, when considered normal newborn

care – facility and practitioner services.

Deductible

What You Pay



Physician services related to maternity care. Deductible

Coinsurance

Copayment

Postpartum home visit (one).** Deductible

Coinsurance

Preventive care, items, and services* as follows:

◼ Items or services with an “A” or “B” rating in the current

recommendations of the United States Preventive Services Task

Force (USPSTF);

◼ Immunizations as recommended by the Advisory Committee on

Immunization Practices of the Centers for Disease Control and

Prevention (ACIP);

◼ Preventive care and screenings for infants, children, and

adolescents provided for in guidelines supported by the Health

Resources and Services Administration (HRSA); and

◼ Preventive care and screenings for women provided for in

guidelines supported by the HRSA.

Deductible

Coinsurance

Copayment

Preventive digital breast tomosynthesis (3D mammogram). Deductible

Coinsurance

Copayment

Preventive prostate-specific antigen (PSA) testing. Deductible

Coinsurance

Copayment

Prosthetic limb devices. Deductible

Services subject to emergency room copayment amounts. Deductible

Services subject to office visit copayment amounts. Deductible

Coinsurance

Services subject to urgent care center copayment amounts. Deductible

Coinsurance

Telehealth services received from domestic providers, UI Quick Care

Clinic, and Wellmark Blue HMO providers.‡

Deductible

Coinsurance

Telehealth services received from practitioners contracting through

Doctor on Demand.‡

Deductible

Coinsurance

Copayment

What You Pay



Voluntary sterilization for female members. Deductible

Coinsurance

Copayment

*A complete list of recommendations and guidelines related to preventive services can be found at www.healthcare.gov. Recommended preventive services are subject to change and are subject to medical management. **If you have a newborn child, but you do not add that child to your coverage, your newborn child may be added to your coverage solely for the purpose of administering benefits for the newborn during the first 48 hours following a vaginal delivery or 96 hours following a cesarean delivery. If that occurs, a separate deductible and coinsurance may be applied to your newborn child unless your coverage specifically waives the deductible or coinsurance for your newborn child. ‡Members can access telehealth services from Doctor on Demand through the Doctor on Demand mobile application or through myWellmark.com.

Prescription Drugs

Coinsurance Coinsurance is the amount you pay,

calculated using a fixed percentage of the

maximum allowable fee, each time a

covered prescription or pharmacy durable

medical equipment device is filled or

refilled.

You pay the entire cost if you purchase a

drug or pharmacy durable medical

equipment device that is not on the

Wellmark Blue Rx Value Plus Drug List. See

Wellmark Blue Rx Value Plus Drug List,

page 34.

Out-of-Pocket Maximum The out-of-pocket maximum is the

maximum you pay in a given benefit year

toward the following amounts:

◼ Coinsurance.

The family out-of-pocket maximum is

reached from applicable amounts paid on

behalf of any combination of covered family

members.


more than the single out-of-pocket

maximum.

However, certain amounts do not apply

toward your out-of-pocket maximum.










equivalent.

These amounts continue even after you have

met your out-of-pocket maximum.

http://www.healthcare.gov/

http://mywellmark.com/

What You Pay


Waived Payment Obligations Some payment obligations are waived for the following covered drugs or services.

Covered Drug or Service Payment Obligation Waived

Generic contraceptive drugs and generic contraceptive drug delivery

devices (e.g., birth control patches).

Payment obligations are also waived if you purchase brand name

contraceptive drugs or brand name drug delivery devices when an

FDA-approved medically appropriate generic equivalent is not

available.

Payment obligations are not waived if you purchase brand name

contraceptive drugs or brand name contraceptive drug delivery devices

when an FDA-approved medically appropriate generic equivalent is

available.

Coinsurance

Preventive items or services* as follows:

◼ Items or services with an “A” or “B” rating in the current

recommendations of the United States Preventive Services Task

Force (USPSTF); and

◼ Immunizations as recommended by the Advisory Committee on

Immunization Practices of the Centers for Disease Control and

Prevention (ACIP).

Coinsurance

Telcare glucometers and Telcare test strips (box of 50) when purchased

from a University of Iowa Hospitals and Clinics pharmacy or a

University of Iowa Hospitals and Clinics Iowa River Landing

Pharmacy.

Coinsurance

Two smoking cessation attempts per calendar year, up to a 90-days'

supply of covered drugs for each attempt, or a 180-days' supply total

per calendar year.

Coinsurance

*A complete list of recommendations and guidelines related to preventive services can be found at www.healthcare.gov. Recommended preventive items and services are subject to change and are subject to medical management.

http://www.healthcare.gov/

Form Number: Wellmark IA Grp/AGC_ 0121 13 WEB T94

2. At a Glance - Covered and Not Covered

Medical

Your coverage provides benefits for many services and supplies received from Network

Providers. There are also services for which this coverage does not provide benefits. The

following chart is provided for your convenience as a quick reference only. This chart is not

intended to be and does not constitute a complete description of all coverage details and factors

that determine whether a service is covered or not. All covered services are subject to the

contract terms and conditions contained throughout this coverage manual. Many of these terms

and conditions are contained in Details – Covered and Not Covered, page 17. To fully

understand which services are covered and which are not, you must become familiar with this

entire coverage manual. Please call us if you are unsure whether a particular service is covered

or not.

The headings in this chart provide the following information:

Category. Service categories are listed alphabetically and are repeated, with additional detailed

information, in Details – Covered and Not Covered.

Covered. The listed category is generally covered, but some restrictions may apply.

Not Covered. The listed category is generally not covered.

See Page. This column lists the page number in Details – Covered and Not Covered where

there is further information about the category.

Benefits Maximums. This column lists maximum benefit amounts that each member is

eligible to receive. Benefits maximums that apply per benefit year or per lifetime are reached

from benefits accumulated under this group health plan and any prior group health plans

sponsored by the University of Iowa and administered by Wellmark Health Plan of Iowa, Inc.

Category C

ove

red

No

t C

ove

red

See

Pag

e

Benefits Maximums

Acupuncture Treatment 17

Allergy Testing and Treatment ⚫ 17

Ambulance Services ⚫ 17

Anesthesia ⚫ 18

Autism Treatment ⚫ 18

Blood and Blood Administration ⚫ 18

Chemical Dependency Treatment ⚫ 18

Chemotherapy and Radiation Therapy ⚫ 19

Clinical Trials – Routine Care Associated with Clinical Trials

⚫ 19

Contraceptives ⚫

19

Conversion Therapy 19

Cosmetic Services ⚫ 19

At A Glance – Covered and Not Covered

WEB T94 14 Form Number: Wellmark IA Grp/AGC_ 0121

Category C

ove

red

No

t C

ove

red

See

Pag

e

Benefits Maximums

Counseling and Education Services 19

Dental Treatment for Accidental Injury ⚫ 20

Dialysis ⚫ 20

Education Services for Diabetes and Nutrition

⚫

21

Emergency Services ⚫ 21

Fertility and Infertility Services ⚫ 21

$15,000 per lifetime for covered services and supplies related to infertility treatment.

Genetic Testing ⚫ 22

Hearing Services ⚫ 22

One routine hearing examination per benefit year. $2,000 during every five consecutive year period for hearing aids and hearing aid evaluation, testing and repairs.

Home Health Services ⚫ 22

The daily benefit for short-term home skilled nursing services will not exceed Wellmark’s daily maximum allowable fee for skilled nursing facility services.

Home/Durable Medical Equipment ⚫ 23

Hospice Services ⚫ 23

15 days per lifetime for inpatient hospice respite care. 15 days per lifetime for outpatient hospice respite care. Please note: Hospice respite care must be used in increments of not more than five days at a time.

Hospitals and Facilities ⚫ 24

Illness or Injury Services ⚫ 24

Inhalation Therapy ⚫ 25

Maternity Services ⚫ 25

Medical and Surgical Supplies and Personal Convenience Items

⚫ 25

Medical Evacuation ⚫ 26

Mental Health Services ⚫ 26

Motor Vehicles 27

Musculoskeletal Treatment ⚫ 27

Nonmedical or Administrative Services 27

Nutritional and Dietary Supplements ⚫ 27

Occupational Therapy ⚫ 27

Orthotics (Foot) 28


Form Number: Wellmark IA Grp/AGC_ 0121 15 WEB T94

Category C

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Physical Therapy ⚫ 28

Physicians and Practitioners 28

Advanced Registered Nurse Practitioners

⚫ 28

Audiologists ⚫ 28

Chiropractors ⚫ 28

Doctors of Osteopathy ⚫ 28

Licensed Independent Social Workers ⚫ 28

Medical Doctors ⚫ 28

Occupational Therapists ⚫ 28

Optometrists ⚫ 28

Oral Surgeons ⚫ 28

Physical Therapists ⚫ 28

Physician Assistants ⚫ 28

Podiatrists ⚫ 28

Psychologists ⚫ 28

Speech and Hearing Practitioners at Wendell Johnson Clinic

⚫ 28

Speech Pathologists ⚫ 28

Platelet-Rich Plasma Injections ⚫ 29

Prescription Drugs ⚫ 29

Preventive Care ⚫ 30

Well-child care until the child reaches age seven.

One routine physical examination per benefit year.

One physical examination required for administrative purposes per benefit year.

One routine mammogram per benefit year.

One routine gynecological examination per benefit year.

One routine Pap smear per benefit year.

Prosthetic Devices ⚫ 31

Reconstructive Surgery ⚫ 31

Repatriation ⚫ 32

Self-Help Programs 32

Sleep Apnea Treatment ⚫ 32

Social Adjustment 32

Speech Therapy ⚫ 32

Surgery ⚫ 32

Telehealth Services ⚫ 32

Temporomandibular Joint Disorder (TMD)

⚫ 33

Transplants ⚫ 33

Travel or Lodging Costs 33


WEB T94 16 Form Number: Wellmark IA Grp/AGC_ 0121

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Vision Services ⚫ 33

One routine vision examination per benefit year.

Wigs or Hairpieces 34

X-ray and Laboratory Services ⚫ 34

Prescription Drugs

Please note: To determine if a drug is covered, you must consult the Wellmark Blue Rx Value

Plus Drug List. You are covered for drugs listed on the Wellmark Blue Rx Value Plus Drug List.

If a drug is not on the Wellmark Blue Rx Value Plus Drug List, it is not covered.

For details on drug coverage, drug limitations, and drug exclusions, see the next section, Details

– Covered and Not Covered.

Form Number: Wellmark IA Grp/DE_ 0121 17 WEB T94

3. Details - Covered and Not Covered

All covered services or supplies listed in this section are subject to the general contract

provisions and limitations described in this coverage manual. Also see the section General

Conditions of Coverage, Exclusions, and Limitations, page 39. If a service or supply is not

specifically listed, do not assume it is covered.

Medical

Acupuncture Treatment Not Covered: Acupuncture and

acupressure treatment.

Allergy Testing and Treatment Covered.

Ambulance Services Covered:

◼ Professional emergency air and ground

ambulance transportation to a hospital

in the surrounding area where your

ambulance transportation originates.

All of the following are required to

qualify for benefits:

⎯ The services required to treat your

illness or injury are not available in

the facility where you are currently

receiving care if you are an inpatient

at a facility.

⎯ You are transported to the nearest

hospital in the Wellmark Blue HMO

network with adequate facilities to

treat your medical condition. In an

emergency situation, you should

seek care at the nearest appropriate

facility, whether the facility is in-

network or out-of-network.

⎯ During transport, your medical

condition requires the services that

are provided only by an air or

ground ambulance that is

professionally staffed and specially

equipped for taking sick or injured

people to or from a health care

facility in an emergency.

⎯ The air or ground ambulance has the

necessary patient care equipment

and supplies to meet your needs.

⎯ Your medical condition requires

immediate and rapid ambulance

transport.

⎯ In addition to the preceding

requirements, for air ambulance

services to be covered, all of the

following must be met:

◼ Your medical condition requires

immediate and rapid air

ambulance transport that cannot

be provided by a ground

ambulance; or the point of pick

up is inaccessible by a land

vehicle.

◼ Great distances, limited time

frames, or other obstacles are

involved in getting you to the

nearest hospital with appropriate

facilities for treatment.

◼ Your condition is such that the

time needed to transport you by

land poses a threat to your

health.

In an emergency situation, if you cannot

reasonably utilize a domestic ambulance

service, covered services will be reimbursed

as though they were received from a

domestic ambulance service.

◼ Professional non-emergency ground

ambulance transportation to a hospital

or nursing facility in the surrounding

area where your ambulance

transportation originates.

All of the following are required to

qualify for benefits:

Details – Covered and Not Covered

WEB T94 18 Form Number: Wellmark IA Grp/DE_ 0121

⎯ The services required to treat your

illness or injury are not available in

the facility where you are currently

receiving care.

⎯ You are transported to the nearest

hospital or nursing facility with

adequate facilities to treat your

medical condition.

⎯ During transport your medical

condition requires the services that

are provided only by a ground

ambulance that is professionally

staffed and specially equipped for

taking sick or injured people to or

from a health care facility.

⎯ The ground ambulance has the

necessary patient care equipment

and supplies to meet your needs.

Not Covered:

◼ Professional air or ground ambulance

transport from a facility capable of

treating your condition.

◼ Professional ground ambulance

transport to or from any location when

you are physically and mentally capable

of being a passenger in a private vehicle.

◼ Professional ground ambulance round-

trip transports from your residence to a

medical provider for an appointment or

treatment and back to your residence.

◼ Professional air or ground transport

when performed primarily for your

convenience or the convenience of your

family, physician, or other health care

provider.

◼ Professional, non-emergency air

ambulance transports to any location for

any reason.

◼ Nonprofessional air or ground

ambulance transports to any location for

any reason. This includes non-

ambulance vehicles such as vans or taxis

that are equipped to transport stretchers

or wheelchairs but are not professionally

operated or staffed.

Anesthesia Covered: Anesthesia and the

administration of anesthesia.

Not Covered: Local or topical anesthesia

billed separately from related surgical or

medical procedures.

Autism Spectrum Disorder Treatment Covered: Diagnosis and treatment of

autism spectrum disorder and Applied

Behavior Analysis services for the treatment

of autism spectrum disorder for members

age 20 and younger when Applied Behavior

Analysis services are performed or

supervised pursuant to an approved

treatment plan by a licensed physician or

psychologist or a master’s or doctoral degree

holder certified by the National Behavior

Analyst Certification Board with a

designation of board certified behavior

analyst.

Not Covered:

◼ Applied Behavior Analysis services for

the treatment of autism spectrum

disorder for members age 21 and older.

◼ Applied Behavior Analysis services other

than for the treatment of autism

spectrum disorder.

Blood and Blood Administration Covered: Blood and blood administration,

including blood derivatives, and blood

components.

Chemical Dependency Treatment Covered: Treatment for a condition with

physical or psychological symptoms

produced by the habitual use of certain

drugs or alcohol as described in the most

current Diagnostic and Statistical Manual

of Mental Disorders.

See Also:

Hospitals and Facilities later in this section.



Chemotherapy and Radiation Therapy Covered: Use of chemical agents or

radiation to treat or control a serious illness.

Clinical Trials – Routine Care Associated with Clinical Trials Covered: Medically necessary routine

patient costs for items and services

otherwise covered under this plan furnished

in connection with participation in an

approved clinical trial related to the

treatment of cancer or other life-threatening

diseases or conditions, when a covered

member is referred by a Network Provider

based on the conclusion that the member is

eligible to participate in an approved clinical

trial according to the trial protocol or the

member provides medical and scientific

information establishing that the member’s

participation in the clinical trial would be

appropriate according to the trial protocol.

Not Covered:

◼ Investigational or experimental items,

devices, or services which are

themselves the subject of the clinical

trial;

◼ Clinical trials, items, and services that

are provided solely to satisfy data

collection and analysis needs and that

are not used in the direct clinical

management of the patient;

◼ Services that are clearly inconsistent

with widely accepted and established

standards of care for a particular

diagnosis.

Contraceptives Covered: The following conception

prevention, as approved by the U.S. Food

and Drug Administration:

◼ Contraceptive medical devices, such as

intrauterine devices and diaphragms.

◼ Implanted contraceptives.

◼ Injected contraceptives.

Please note: Contraceptive drugs and

contraceptive drug delivery devices, such as

insertable rings and patches are covered

under your Blue Rx Value Plus prescription

drug benefits described later in this section.

See the Wellmark Blue Rx Value Plus Drug

List at Wellmark.com or call the Customer

Service number on your ID card and request

a copy of the Drug List.

Conversion Therapy Not Covered: Conversion therapy services.

Cosmetic Services Covered: Cosmetic services, supplies, or

drugs only if provided primarily to restore

function, lost or impaired, as the result of an

illness, accidental injury, or a birth defect.

Benefits Maximum:

◼ Restorative dental services required as

the result of an accidental injury must

be received within 18 months following

the date of accident.

Not Covered: Cosmetic services, supplies,

or drugs provided primarily to improve

physical appearance. You are not covered

for treatment for any complications

resulting from a noncovered cosmetic

procedure.

See Also:

Reconstructive Surgery later in this section.

Counseling and Education Services Not Covered:

◼ Bereavement counseling or services.

◼ Family or marriage counseling or

training services.

◼ Community-based services or services of

volunteers or clergy.

◼ Learning and educational services and

treatments including, but not limited to,

non-drug therapy for high blood

pressure control, exercise modalities for

weight reduction, nutritional instruction

for the control of gastrointestinal



conditions, or reading programs for

dyslexia for any medical, mental health,

or substance abuse condition.

◼ Weight reduction programs or supplies

(including dietary supplements, foods,

equipment, lab testing, examinations,

and prescription drugs), whether or not

weight reduction is medically

appropriate.

See Also:

Genetic Testing later in this section.

Education Services for Diabetes and

Nutrition later in this section.

Mental Health Services later in this section.

Preventive Care later in this section.

Dental Services Covered:

◼ Dental treatment for accidental injuries

when all of the following requirements

are met:

⎯ Treatment is completed within 12

months of the injury.

⎯ Follow-up treatment for any

cosmetic repairs related to the

accidental injury must be completed

within 18 months.

◼ Anesthesia (general) and hospital or

ambulatory surgical facility services

related to covered dental services if:

⎯ You are under age 14 and, based on a

determination by a licensed dentist

and your treating physician, you

have a dental or developmental

condition for which patient

management in the dental office has

been ineffective and requires dental

treatment in a hospital or

ambulatory surgical facility; or

⎯ Based on a determination by a

licensed dentist and your treating

physician, you have one or more

medical conditions that would create

significant or undue medical risk in

the course of delivery of any

necessary dental treatment or

surgery if not rendered in a hospital

or ambulatory surgical facility.

◼ Impacted teeth removal (surgical) only

when you have a medical condition

(such as hemophilia) that requires

hospitalization.

◼ Facial bone fracture reduction.

◼ Incisions of accessory sinus, mouth,

salivary glands, or ducts.

◼ Jaw dislocation manipulation.

◼ Orthodontic services associated with

management of cleft palate.

◼ Treatment of abnormal changes in the

mouth due to injury or disease of the

mouth, or dental care (oral examination,

x-rays, extractions, and nonsurgical

elimination of oral infection) required

for the direct treatment of a medical

condition, limited to:

⎯ Dental services related to medical

transplant procedures;

⎯ Initiation of immunosuppressives

(medication used to reduce

inflammation and suppress the

immune system); or

⎯ Treatment of neoplasms of the

mouth and contiguous tissue.

Not Covered:

◼ General dentistry including, but not

limited to, diagnostic and preventive

services, restorative services, endodontic

services, periodontal services, indirect

fabrications, dentures and bridges, and

orthodontic services unrelated to

accidental injuries or management of

cleft palate.

◼ Injuries associated with or resulting

from the act of chewing.

◼ Maxillary or mandibular tooth implants

(osseointegration) unrelated to

accidental injuries or abnormal changes

in the mouth due to injury or disease.

Dialysis Covered: Removal of toxic substances

from the blood when the kidneys are unable

to do so when provided as an inpatient in a



hospital setting or as an outpatient in a

Medicare-approved dialysis center.

Education Services for Diabetes and Nutrition Covered: Inpatient and outpatient training

and education for the self-management of

all types of diabetes mellitus.

All covered training or education must be

prescribed by a licensed physician.

Outpatient training or education must be

provided by a state-certified program.

The state-certified diabetic education

program helps any type of diabetic and his

or her family understand the diabetes

disease process and the daily management

of diabetes.

You are also covered for nutrition education

to improve your understanding of your

metabolic nutritional condition and provide

you with information to manage your

nutritional requirements. Nutrition

education is appropriate for the following

conditions:

◼ Cancer.

◼ Cystic fibrosis.

◼ Diabetes.

◼ Eating disorders.

◼ Glucose intolerance.

◼ High blood pressure.

◼ High cholesterol.

◼ Lactose intolerance.

◼ Malabsorption, including gluten

intolerance.

◼ Morbid obesity.

◼ Underweight.

Emergency Services Covered: When treatment is for a medical

condition manifested by acute symptoms of

sufficient severity, including pain, that a

prudent layperson, with an average

knowledge of health and medicine, could

reasonably expect absence of immediate

medical attention to result in:

◼ Placing the health of the individual or,

with respect to a pregnant woman, the

health of the woman and her unborn

child, in serious jeopardy; or

◼ Serious impairment to bodily function;

or

◼ Serious dysfunction of any bodily organ

or part.

In an emergency situation, if you cannot

reasonably reach a domestic provider,

covered services will be reimbursed as

though they were received from a domestic

provider. However, because we do not have

contracts with Out-of-Network Providers

and they may not accept our payment

arrangements, you are responsible for any

difference between the amount charged and

our amount paid for a covered service.

See Also:

Out-of-Network Providers, page 61.

Fertility and Infertility Services Covered:

◼ Fertility prevention, such as tubal

ligation (or its equivalent) or vasectomy

(initial surgery only).

◼ Infertility testing and treatment for

infertile members including in vitro

fertilization, gamete intrafallopian

transfer (GIFT), and pronuclear stage

transfer (PROST).

◼ The collection or purchase of donor

semen (sperm) or oocytes (eggs) when

performed in connection with fertility or

infertility procedures; freezing of sperm,

oocytes, or embryos.

◼ Reversal of a tubal ligation (or its

equivalent) or vasectomy.

Benefits Maximum:

◼ $15,000 per lifetime for covered

services and supplies related to

infertility treatment.



Not Covered:

◼ Surrogate parent services.

Genetic Testing Covered: Genetic molecular testing

(specific gene identification) and related

counseling are covered when both of the

following requirements are met:

◼ You are an appropriate candidate for a

test under medically recognized

standards (for example, family

background, past diagnosis, etc.).

◼ The outcome of the test is expected to

determine a covered course of treatment

or prevention and is not merely

informational.

Hearing Services Covered:

◼ Routine hearing examinations.

◼ Hearing aids.

Benefits Maximum:

◼ One routine hearing examination per

benefit year.

◼ $2,000 during every five consecutive

year period for hearing aids and hearing

aid evaluation, testing and repairs.

Home Health Services Covered: All of the following requirements

must be met in order for home health

services to be covered:

◼ You require a medically necessary

skilled service such as skilled nursing,

physical therapy, or speech therapy.

◼ Services are received from an agency

accredited by the Joint Commission for

Accreditation of Health Care

Organizations (JCAHO) and/or a

Medicare-certified agency.

◼ Services are prescribed by a physician

and approved by Wellmark for the

treatment of illness or injury.

◼ Services are not more costly than

alternative services that would be

effective for diagnosis and treatment of

your condition.

◼ The care is referred by a Network

Provider and approved by Wellmark.

The following are covered services and

supplies:

Home Health Aide Services—when

provided in conjunction with a

medically necessary skilled service also

received in the home.

Short-Term Home Skilled

Nursing. Treatment must be given by a

registered nurse (R.N.) or licensed

practical nurse (L.P.N.) from an agency

accredited by the Joint Commission for

Accreditation of Health Care

Organizations (JCAHO) or a Medicare-

certified agency. Short-term home

skilled nursing means home skilled

nursing care that:

⎯ is provided for a definite limited

period of time as a safe transition

from other levels of care when

medically necessary;

⎯ provides teaching to caregivers for

ongoing care; or

⎯ provides short-term treatments that

can be safely administered in the

home setting.

The daily benefit for short-term home

skilled nursing services will not exceed

Wellmark’s daily maximum allowable

fee for care in a skilled nursing facility.

Benefits do not include maintenance or

custodial care or services provided for

the convenience of the family caregiver.

Inhalation Therapy.

Medical Equipment.

Medical Social Services.

Medical Supplies.

Occupational Therapy—but only for

services to treat the upper extremities,

which means the arms from the

shoulders to the fingers. You are not

covered for occupational therapy

supplies.



Oxygen and Equipment for its

administration.

Parenteral and Enteral Nutrition,

except enteral formula administered

orally.

Physical Therapy.

Prescription Drugs and Medicines

administered in the vein or muscle.

Prosthetic Devices and Braces.

Speech Therapy.

Not Covered:

◼ Custodial home care services and

supplies, which help you with your daily

living activities. This type of care does

not require the continuing attention and

assistance of licensed medical or trained

paramedical personnel. Some examples

of custodial care are assistance in

walking and getting in and out of bed;

aid in bathing, dressing, feeding, and

other forms of assistance with normal

bodily functions; preparation of special

diets; and supervision of medication

that can usually be self-administered.

You are also not covered for sanitaria

care or rest cures.

◼ Extended home skilled nursing.

See Also:

Referrals, page 45.

Home/Durable Medical Equipment Covered: Equipment that meets all of the

following requirements:

◼ The equipment is ordered by a provider

within the scope of his or her license and

there is a written prescription.

◼ Durable enough to withstand repeated

use.

◼ Primarily and customarily

manufactured to serve a medical

purpose.

◼ Used to serve a medical purpose.

◼ Standard or basic home/durable

medical equipment that will adequately

meet the medical needs and that does

not have certain deluxe/luxury or

convenience upgrade or add-on features.

In addition, we determine whether to pay

the rental amount or the purchase price

amount for an item, and we determine the

length of any rental term. Benefits will never

exceed the lesser of the amount charged or

the maximum allowable fee.

See Also:

Medical and Surgical Supplies and

Personal Convenience Items later in this

section.

Orthotics (Foot) later in this section.

Prosthetic Devices later in this section.

Referrals, page 45.

Hospice Services Covered: Care (generally in a home

setting) for patients who are terminally ill

and who have a life expectancy of six

months or less. Hospice care covers the

same services as described under Home

Health Services, as well as hospice respite

care from a facility approved by Medicare or

by the Joint Commission for Accreditation

of Health Care Organizations (JCAHO).

Hospice respite care offers rest and relief

help for the family caring for a terminally ill

patient. Inpatient respite care can take place

in a nursing home, nursing facility, or

hospital.

Benefits Maximum:

◼ 15 days per lifetime for inpatient

hospice respite care.

◼ 15 days per lifetime for outpatient

hospice respite care.

◼ Not more than five days of hospice

respite care at a time.



Hospitals and Facilities Covered: Hospitals and other facilities that

meet standards of licensing, accreditation or

certification. Following are some recognized

facilities:

Ambulatory Surgical Facility. This

type of facility provides surgical services

on an outpatient basis for patients who

do not need to occupy an inpatient

hospital bed and must be licensed as an

ambulatory surgical facility under

applicable law.

Chemical Dependency Treatment

Facility. This type of facility must be

licensed as a chemical dependency

treatment facility under applicable law.

Community Mental Health Center.

This type of facility provides treatment

of mental health conditions and must be

licensed as a community mental health

center under applicable law.

Hospital. This type of facility provides

for the diagnosis, treatment, or care of

injured or sick persons on an inpatient

and outpatient basis. The facility must

be licensed as a hospital under

applicable law.

Nursing Facility. This type of facility

provides continuous skilled nursing

services as ordered and certified by your

attending physician on an inpatient

basis for short-term care. Benefits do

not include maintenance or custodial

care or services provided for the

convenience of the family caregiver. The

facility must be licensed as a nursing

facility under applicable law.

Residential Treatment Facility.

This type of facility provides treatment

for severe, persistent, or chronic mental

health conditions or chemical

dependency that meets all of the

following criteria:

⎯ Treatment is provided in a 24-hour

residential setting.

⎯ Treatment involves therapeutic

intervention and specialized

programming with a high degree of

structure and supervision.

⎯ Treatment includes training in basic

skills such as social skills and

activities of daily living.

⎯ Treatment does not require daily

supervision of a physician.

Psychiatric Medical Institution for

Children (PMIC). This type of facility

provides inpatient psychiatric services to

children and is licensed as a PMIC under

Iowa Code Chapter 135H.

Precertification is required. For

information on how to precertify, refer

to Precertification in the Notification

Requirements and Care Coordination

section of this coverage manual, or call

the Customer Service number on your

ID card.

Not Covered:

◼ Long Term Acute Care Facility.

See Also:

Chemical Dependency Treatment earlier in

this section.

Mental Health Services later in this section.

Illness or Injury Services Covered:

◼ Services or supplies used to treat any

bodily disorder, bodily injury, disease,

or mental health condition unless

specifically addressed elsewhere in this

section. This includes pregnancy and

complications of pregnancy.

◼ Routine foot care related to the

treatment of a metabolic, neurological,

or peripheral vascular disease.

Treatment may be received from an

approved provider in any of the following

settings:

◼ Home.

◼ Inpatient (such as a hospital or nursing

facility).

◼ Office (such as a doctor’s office).



◼ Outpatient.

Not Covered:

◼ Long term acute care services typically

provided by a long term acute care

facility.

◼ Routine foot care, including related

services or supplies, except as described

under Covered.

Inhalation Therapy Covered: Respiratory or breathing

treatments to help restore or improve

breathing function.

Maternity Services Covered: Prenatal and postnatal care,

delivery, including complications of

pregnancy. A complication of pregnancy

refers to a cesarean section that was not

planned, an ectopic pregnancy that is

terminated, or a spontaneous termination of

pregnancy that occurs during a period of

gestation in which a viable birth is not

possible. Complications of pregnancy also

include conditions requiring inpatient

hospital admission (when pregnancy is not

terminated) whose diagnoses are distinct

from pregnancy but are adversely affected

by pregnancy or are caused by pregnancy.

Please note: You must notify us or the

University of Iowa if you enter into an

arrangement to provide surrogate parent

services: Contact the University of Iowa or

call the Customer Service number on your

ID card.

In accordance with federal or applicable

state law, maternity services include a

minimum of:

◼ 48 hours of inpatient care (in addition to

the day of delivery care) following a

vaginal delivery, or

◼ 96 hours of inpatient care (in addition to

the day of delivery) following a cesarean

section.

A practitioner is not required to seek

Wellmark’s review in order to prescribe a

length of stay of less than 48 or 96 hours.

The attending practitioner, in consultation

with the mother, may discharge the mother

or newborn prior to 48 or 96 hours, as

applicable.

Coverage includes one follow-up

postpartum home visit by a registered nurse

(R.N.). This nurse must be from a home

health agency under contract with Wellmark

or employed by the delivering physician.

If you have a newborn child, but you do not

add that child to your coverage, your

newborn child may be added to your

coverage solely for the purpose of

administering benefits for the newborn

during the first 48 hours following a vaginal

delivery or 96 hours following a cesarean

delivery. If that occurs, a separate

deductible and coinsurance may be applied

to your newborn child unless your coverage

specifically waives the deductible or

coinsurance for your newborn child.

See Also:

Coverage Change Events, page 71.

Medical and Surgical Supplies and Personal Convenience Items Covered: Medical supplies and devices

such as:

◼ Dressings and casts.

◼ Oxygen and equipment needed to

administer the oxygen.

◼ Diabetic equipment and

supplies purchased from a covered

provider.

Not Covered: Unless otherwise required

by law, supplies, equipment, or drugs

available for general retail purchase or items

used for your personal convenience

including, but not limited to:

◼ Band-aids, gauze, bandages, tape, non-

sterile gloves, thermometers, heating

pads, cooling devices, cold packs,

heating devices, hot water bottles, home

enema equipment, sterile water, bed



boards, alcohol wipes, or incontinence

products;

◼ Elastic stockings or bandages including

trusses, lumbar braces, garter belts, and

similar items that can be purchased

without a prescription;

◼ Escalators, elevators, ramps, stair glides,

emergency/alert equipment, handrails,

heat appliances, improvements made to

a member's house or place of business,

or adjustments made to vehicles;

◼ Household supplies including, but not

limited to: deluxe/luxury equipment or

non-essential features, such as motor-

driven chairs or bed, electric stair chairs

or elevator chairs, or sitz bath;

◼ Items not primarily and customarily

manufactured to serve a medical

purpose or which can be used in the

absence of illness or injury including,

but not limited to, air conditioners, hot

tubs, or swimming pools;

◼ Items that do not serve a medical

purpose or are not needed to serve a

medical purpose;

◼ Rental or purchase of equipment if you

are in a facility which provides such

equipment;

◼ Rental or purchase of exercise cycles,

physical fitness, exercise and massage

equipment, ultraviolet/tanning

equipment, or traction devices; and

◼ Water purifiers, hypo-allergenic pillows,

mattresses or waterbeds, whirlpool, spa,

air purifiers, humidifiers, or

dehumidifiers.

See Also:

Home/Durable Medical Equipment earlier

in this section.

Orthotics (Foot) later in this section.

Prescription Drugs, page 34.


Medical Evacuation Covered: Medical evacuation services if

you become ill or have an injury at a

location where adequate medical care

cannot be provided. The medical evacuation

generally will be to the nearest adequate

medical facility. If you are from outside the

United States, medical evacuation may be

either to the nearest adequate medical

facility or to your home country. This

benefit applies to the employee, spouse,

domestic partner, or child covered under

this medical benefits plan.

See Also:

Precertification, page 53.

Mental Health Services Covered: Treatment for certain

psychiatric, psychological, or emotional

conditions as an inpatient or outpatient.

Covered facilities for mental health services

include licensed and accredited residential

treatment facilities and community mental

health centers.

To qualify for mental health treatment

benefits, the following requirements must

be met:

◼ The disorder is classified as a mental

health condition in the Diagnostic and

Statistical Manual of Mental Disorders,

Fifth Edition (DSM-V) or subsequent

revisions, except as otherwise provided

in this coverage manual.

◼ The disorder is listed only as a mental

health condition and not dually listed

elsewhere in the most current version of

International Classification of Diseases,

Clinical Modification used for diagnosis

coding.

Not Covered: Treatment for:

◼ Certain disorders related to early

childhood, such as academic

underachievement disorder.

◼ Communication disorders, such as

stuttering and stammering.

◼ Impulse control disorders.

◼ Conditions that are not pervasive

developmental and learning disorders.

◼ Sensitivity, shyness, and social

withdrawal disorders.

◼ Sexual disorders.



See Also:

Chemical Dependency Treatment and

Hospitals and Facilities earlier in this

section.

Motor Vehicles Not Covered: Purchase or rental of motor

vehicles such as cars or vans. You are also

not covered for equipment or costs

associated with converting a motor vehicle

to accommodate a disability.

Musculoskeletal Treatment Covered: Outpatient nonsurgical

treatment of ailments related to the

musculoskeletal system, such as

manipulations or related procedures to treat

musculoskeletal injury or disease.

Not Covered: Massage therapy.

Nonmedical or Administrative Services Not Covered: Such services as telephone

consultations, charges for failure to keep

scheduled appointments, charges for

completion of any form, charges for medical

information, recreational therapy and other

sensory-type activities, administrative

services (such as interpretive services, pre-

care assessments, health risk assessments,

case management, care coordination, or

development of treatment plans) when

billed separately, and any services or

supplies that are nonmedical.

Nutritional and Dietary Supplements Covered:

◼ Nutritional and dietary supplements

that cannot be dispensed without a

prescription issued by or authorized by a

licensed health care practitioner and are

prescribed by a licensed health care

practitioner for permanent inborn

errors of metabolism, such as PKU.

◼ Enteral and nutritional therapy only

when prescribed feeding is administered

through a feeding tube, except for

permanent inborn errors of metabolism.

Not Covered: Other prescription and non-

prescription nutritional and dietary

supplements including, but not limited to:

◼ Food products.

◼ Grocery items or food products that are

modified for special diets for individuals

with inborn errors of metabolism but

which can be purchased without a

prescription issued by or authorized by a

licensed healthcare practitioner,

including low protein/low phe grocery

items.

◼ Herbal products.

◼ Fish oil products.

◼ Medical foods, except as described

under Covered.

◼ Minerals.

◼ Supplementary vitamin preparations.

◼ Multivitamins.

Occupational Therapy Covered: Occupational therapy services

are covered when all the following

requirements are met:

◼ Services are to treat the upper

extremities, which means the arms from

the shoulders to the fingers.

◼ The goal of the occupational therapy is

improvement of an impairment or

functional limitation.

◼ The potential for rehabilitation is

significant in relation to the extent and

duration of services.

◼ The expectation for improvement is in a

reasonable (and generally predictable)

period of time.

◼ There is evidence of improvement by

successive objective measurements

whenever possible.

Not Covered:

◼ Occupational therapy supplies.

◼ Occupational therapy provided as an

inpatient in the absence of a separate

medical condition that requires

hospitalization.



◼ Occupational therapy performed for

maintenance.

◼ Occupational therapy services that do

not meet the requirements specified

under Covered.

Orthotics (Foot) Covered: Orthotics training.

Not Covered: Orthotic foot devices such as

arch supports or in-shoe supports,

orthopedic shoes, elastic supports, or

examinations to prescribe or fit such

devices.

See Also:


in this section.


Physical Therapy Covered: Physical therapy services are

covered when all the following requirements

are met:

◼ The goal of the physical therapy is

improvement of an impairment or

functional limitation.

◼ The potential for rehabilitation or

habilitation is significant in relation to

the extent and duration of services.

◼ The expectation for improvement is in a

reasonable (and generally predictable)

period of time.

◼ There is evidence of improvement by

successive objective measurements

whenever possible.

Not Covered:

◼ Physical therapy provided as an

inpatient in the absence of a separate

medical condition that requires

hospitalization.

◼ Physical therapy performed for

maintenance.

◼ Physical therapy services that do not

meet the requirements specified under

Covered.

Physicians and Practitioners Covered: Most services provided by

practitioners that are recognized by us and

meet standards of licensing, accreditation or

certification. Following are some recognized

physicians and practitioners:

Advanced Registered Nurse

Practitioners (ARNP). An ARNP is a

registered nurse with advanced training

in a specialty area who is registered with

the Iowa Board of Nursing to practice in

an advanced role with a specialty

designation of certified clinical nurse

specialist, certified nurse midwife,

certified nurse practitioner, or certified

registered nurse anesthetist.

Audiologists.

Chiropractors.

Doctors of Osteopathy (D.O.).

Licensed Independent Social

Workers.

Medical Doctors (M.D.).

Occupational Therapists. This

provider is covered only when treating

the upper extremities, which means the

arms from the shoulders to the fingers.

Optometrists.

Oral Surgeons.

Physical Therapists.

Physician Assistants.

Podiatrists.

Psychologists. Psychologists must

have a doctorate degree in psychology

with two years’ clinical experience and

meet the standards of a national

register.

Speech and Hearing Practitioners

at Wendell Johnson Clinic.

Speech Pathologists.

See Also:

Choosing a Provider, page 45.



Platelet-Rich Plasma Injections Covered: Platelet-rich plasma injections,

including image guidance, harvesting, and

preparation when performed.

Prescription Drugs Covered: Most prescription drugs and

medicines that bear the legend, “Caution,

Federal Law prohibits dispensing without a

prescription,” are generally covered under

your Blue Rx Value Plus prescription drug

benefits, not under your medical benefits.

However, there are exceptions when

prescription drugs and medicines are

covered under your medical benefits.

Drugs classified by the FDA as Drug Efficacy

Study Implementation (DESI) drugs may

also be covered. For a list of these drugs,

visit our website at Wellmark.com or check

with your pharmacist or physician.

Drugs listed on the Drug List are established

and maintained by Wellmark’s Pharmacy &

Therapeutics (P&T) Committee. The P&T

Committee is a group of independent

practicing healthcare providers such as

physicians and pharmacists who regularly

meet to review the safety, effectiveness, and

value of new and existing medications and

make any necessary changes to the coverage

of medications. Drugs will not be covered

until they have been evaluated and

approved to be covered by Wellmark’s P&T

Committee. Drugs previously approved by

Wellmark’s P&T Committee will no longer

be covered if Wellmark’s P&T Committee

discontinues approval of the drugs.

Prescription drugs and medicines that may

be covered under your medical benefits

include:

Drugs and Biologicals. Drugs and

biologicals approved by the U.S. Food

and Drug Administration. This includes

such supplies as serum, vaccine,

antitoxin, or antigen used in the

prevention or treatment of disease.

Intravenous Administration.

Intravenous administration of nutrients,

antibiotics, and other drugs and fluids

when provided in the home (home

infusion therapy).

Specialty Drugs. Specialty drugs are

high-cost injectable, infused, oral, or

inhaled drugs typically used for treating

or managing chronic illnesses. These

drugs often require special handling

(e.g., refrigeration) and administration.

They are not available through the mail

order drug program.

Specialty drugs may be covered under

your medical benefits or under your

Blue Rx Value Plus prescription drug

benefits. If a specialty drug that is

covered under your medical benefits is

not provided by your physician, you

must purchase specialty drugs through

the specialty pharmacy program. To

determine whether a particular specialty

drug is covered under your medical

benefits or under your Blue Rx Value

Plus prescription drug benefits, consult

the Wellmark Blue Rx Value Plus Drug

List at Wellmark.com, or call the

Customer Service number on your ID

card. See Specialty Drugs, page 52.

You are not covered for specialty drugs

purchased outside the specialty

pharmacy program unless the specialty

drug is covered under your medical

benefits.

Take-Home Drugs. Take-home drugs

are drugs dispensed and billed by a

hospital or other facility for a short-term

supply.

Not Covered: Some prescription drugs,

services, and items are not covered under

either your medical benefits or your Blue Rx

Value Plus benefits. For example:

◼ Antigen therapy.



◼ Medication Therapy Management

(MTM) when billed separately.

◼ Drugs purchased outside the United

States failing the requirements specified

earlier in this section.




has an FDA-approved "A"-rated


equivalent.

◼ Prescription drugs or pharmacy durable

medical equipment devices that are not

FDA-approved.

◼ Prescription drugs that are not approved

to be covered by Wellmark’s P&T

Committee.

Some prescription drugs are covered under

your Blue Rx Value Plus benefits:

◼ Insulin.

See the Wellmark Blue Rx Value Plus Drug

List at Wellmark.com or call the Customer

Service number on your ID card and request

a copy of the Drug List.

See Also:

Contraceptives earlier in this section.


Personal Convenience Items earlier in this

section.

Notification Requirements and Care

Coordination, page 53.

Prescription Drugs later in this section.

Prior Authorization, page 57.

Preventive Care Covered: Preventive care such as:

◼ Breastfeeding support, supplies, and

one-on-one lactation consultant

services, including counseling and

education, provided during pregnancy

and/or the duration of breastfeeding

received from a provider acting within

the scope of their licensure or

certification under state law.

◼ Digital breast tomosynthesis (3D

mammogram).

◼ Gynecological examinations.

◼ Mammograms.

◼ Medical evaluations and counseling for

nicotine dependence per U.S. Preventive

Services Task Force (USPSTF)

guidelines.

◼ Pap smears.

◼ Physical examinations.

◼ Physical examinations required for

administrative purposes.

◼ Preventive items and services including,

but not limited to:

⎯ Items or services with an “A” or “B”

rating in the current

recommendations of the United

States Preventive Services Task

Force (USPSTF);

⎯ Immunizations as recommended by

the Advisory Committee on

Immunization Practices of the

Centers for Disease Control and

Prevention (ACIP);

⎯ Preventive care and screenings for

infants, children and adolescents

provided for in the guidelines

supported by the Health Resources

and Services Administration

(HRSA); and

⎯ Preventive care and screenings for

women provided for in guidelines

supported by the HRSA.

◼ Well-child care including age-

appropriate pediatric preventive

services, as defined by current

recommendations for Preventive

Pediatric Health Care of the American

Academy of Pediatrics. Pediatric

preventive services shall include, at

minimum, a history and complete

physical examination as well as

developmental assessment, anticipatory

guidance, immunizations, and

laboratory services including, but not

limited to, screening for lead exposure

as well as blood levels.



To qualify for benefits, you must receive

preventive care from providers listed in your

provider directory under any of the

following categories:

◼ Advanced registered nurse practitioner

(ARNP).

◼ Family Practice/General Practice.

◼ Internal Medicine.

◼ Pediatrics and Obstetrics/Gynecology.

◼ Physician Assistant (PA).

However, you may also receive covered

immunizations from Network Public Health

Agencies or Network Visiting Nurse

Associations.

Benefits Maximum:

◼ Well-child care until the child reaches

age seven.

◼ One routine physical examination per

benefit year.

◼ One physical examination required for

administrative purposes per benefit

year.

◼ One routine mammogram per benefit

year.

◼ One routine gynecological examination

per benefit year.

◼ One routine Pap smear per benefit year.

Please note: Physical examination limits

do not include items or services with an “A”

or “B” rating in the current

recommendations of the USPSTF,

immunizations as recommended by ACIP,

and preventive care and screening

guidelines supported by the HRSA, as

described under Covered.

Not Covered:

◼ Group lactation consultant services.

◼ All treatment related to nicotine

dependence, except as described under

Covered. For prescription drugs and

devices used to treat nicotine

dependence, including over-the-counter

drugs prescribed by a physician, please

see your Blue Rx Value Plus prescription

drug benefits.

See Also:

Hearing Services earlier in this section.

Vision Services later in this section.

Prosthetic Devices Covered: Devices used as artificial

substitutes to replace a missing natural part

of the body or to improve, aid, or increase

the performance of a natural function.

Also covered are braces, which are rigid or

semi-rigid devices commonly used to

support a weak or deformed body part or to

restrict or eliminate motion in a diseased or

injured part of the body. Braces do not

include elastic stockings, elastic bandages,

garter belts, arch supports, orthodontic

devices, or other similar items.

Not Covered:

◼ Elastic stockings or bandages including

trusses, lumbar braces, garter belts, and

similar items that can be purchased

without a prescription.

See Also:


in this section.


Personal Convenience Items earlier in this

section.

Orthotics (Foot) earlier in this section.

Referrals, page 45.

Reconstructive Surgery Covered: Reconstructive surgery primarily

intended to restore function lost or

impaired as the result of an illness, injury,

or a birth defect (even if there is an

incidental improvement in physical

appearance) including breast reconstructive

surgery following mastectomy. Breast

reconstructive surgery includes the

following:

◼ Reconstruction of the breast on which

the mastectomy has been performed.



◼ Surgery and reconstruction of the other

breast to produce a symmetrical

appearance.

◼ Prostheses.

◼ Treatment of physical complications of

the mastectomy, including

lymphedemas.

See Also:

Cosmetic Services earlier in this section.

Repatriation Covered: In the event of death, expenses

related to returning the body to the person’s

place of residence in his or her current

home country. Related repatriation

expenses may include costs of embalming or

cremation, the coffin or urn, and

transportation of the body or receptacle.

This benefit applies to the employee,

spouse, domestic partner, or child covered

under this medical benefits plan.

Not Covered: This benefit does not

include the transportation expenses of

persons accompanying the body.

Self-Help Programs Not Covered: Self-help and self-cure

products or drugs.

Sleep Apnea Treatment Covered: Obstructive sleep apnea

diagnosis and treatments.

Not Covered: Treatment for snoring

without a diagnosis of obstructive sleep

apnea.

Social Adjustment Not Covered: Services or supplies

intended to address social adjustment or

economic needs that are typically not

medical in nature.

Speech Therapy Covered: Rehabilitative speech therapy

services when related to a specific illness,

injury, or impairment, including speech

therapy services for the treatment of autism

spectrum disorder, that involve the

mechanics of phonation, articulation, or

swallowing. Services must be provided by a

licensed or certified speech pathologist.

Not Covered:

◼ Speech therapy services not provided by

a licensed or certified speech

pathologist.

◼ Speech therapy to treat certain

developmental, learning, or

communication disorders, such as

stuttering and stammering.

Surgery Covered. This includes the following:

◼ Major endoscopic procedures.

◼ Operative and cutting procedures.

◼ Preoperative and postoperative care.

◼ Gender reassignment surgery.

See Also:

Dental Services earlier in this section.

Reconstructive Surgery earlier in this

section.

Telehealth Services Covered: You are covered for telehealth

services delivered to you by a covered

practitioner acting within the scope of his or

her license or certification or by a

practitioner contracting through Doctor on

Demand via real-time, interactive audio-

visual technology or web-based mobile

device or similar electronic-based

communication network. Services must be

delivered in accordance with applicable law

and generally accepted health care

practices.

Please note: Members can access

telehealth services from Doctor on Demand

through the Doctor on Demand mobile

application or through myWellmark.com.

http://mywellmark.com/



Not Covered: Medical services provided

through means other than interactive, real-

time audio-visual technology, including, but

not limited to, audio-only telephone,

electronic mail message, or facsimile

transmission. You are also not covered for

telehealth mental health and chemical

dependency services from Doctor on

Demand.

Temporomandibular Joint Disorder (TMD) Covered.

Not Covered: Routine dental services,

dental extractions, dental restorations, or

orthodontic treatment for

temporomandibular joint disorders.

Transplants Covered:

◼ Certain bone marrow/stem cell transfers

from a living donor.

◼ Heart.

◼ Heart and lung.

◼ Kidney.

◼ Liver.

◼ Lung.

◼ Pancreas.

◼ Simultaneous pancreas/kidney.

◼ Small bowel.

You are also covered for the medically

necessary expenses of transporting the

recipient when the transplant organ for the

recipient is available for transplant.

Transplants are subject to case

management.

Charges related to the donation of an organ

are usually covered by the recipient’s

medical benefits plan. However, if donor

charges are excluded by the recipient’s plan,

and you are a donor, the charges will be

covered by your medical benefits.

Please note: To qualify for benefits, the

transplant facility services specified under

Covered must be from the University of

Iowa Hospitals and Clinics or a facility

recognized as a Wellmark Blue HMO Blue

Distinction® Center for Transplants at the

time of service. This requirement does not

apply to kidney or small bowel transplants

or for practitioner services.

Not Covered:

◼ Expenses of transporting the recipient

when the transplant organ for the

recipient is not available for transplant.

◼ Expenses of transporting a living donor.

◼ Expenses related to the purchase of any

organ.

◼ Services or supplies related to

mechanical or non-human organs

associated with transplants.

◼ Transplant services and supplies not

listed in this section including

complications.

See Also:

Ambulance Services earlier in this section.

Case Management, page 56.

Referrals, page 45.

Travel or Lodging Costs Not Covered.

Vision Services Covered:

◼ Routine vision examinations.

◼ Eyeglasses, but only when prescribed as

the result of cataract extraction.

◼ Contact lenses and associated lens

fitting, but only when prescribed as the

result of cataract extraction or when the

underlying diagnosis is a corneal injury

or corneal disease.

Benefits Maximum:

◼ One routine vision examination per

benefit year.

Not Covered:

◼ Surgery and services to diagnose or

correct a refractive error, including

intraocular lenses and laser vision

correction surgery (e.g., LASIK surgery).



◼ Eyeglasses, contact lenses, or the

examination for prescribing or fitting of

eyeglasses or contact lenses, except

when prescribed as the result of cataract

extraction or when the underlying

diagnosis is a corneal injury or disease.

Wigs or Hairpieces Not Covered.

X-ray and Laboratory Services Covered: Tests, screenings, imagings, and

evaluation procedures as identified in the

American Medical Association's Current

Procedural Terminology (CPT) manual,

Standard Edition, under Radiology

Guidelines and Pathology and Laboratory

Guidelines.

See Also:

Preventive Care earlier in this section.

Prescription Drugs

Guidelines for Drug Coverage To be covered, a prescription drug or

pharmacy durable medical equipment

device must meet all of the following

criteria:

◼ Listed on the Wellmark Blue Rx Value

Plus Drug List.

◼ Can be legally obtained in the United

States only with a written prescription.

◼ Deemed both safe and effective by the

U.S. Food and Drug Administration

(FDA) and approved for use by the FDA

after 1962.

◼ Prescribed by a practitioner prescribing

within the scope of his or her license.

◼ Dispensed by a recognized licensed

retail pharmacy employing licensed

registered pharmacists, through the mail

order drug program, or dispensed and

billed by a hospital or other facility as a

take-home drug for a short-term supply.

◼ Medically necessary for your condition.

See Medically Necessary, page 39.

◼ Not available in an equivalent over-the-

counter strength. However, certain over-

the-counter products and over-the-

counter nicotine dependency drugs

prescribed by a physician may be

covered. To determine if a particular

over-the-counter product is covered, call

the Customer Service number on your

ID card.

◼ Reviewed, evaluated, and recommended

for addition to the Wellmark Blue Rx

Value Plus Drug List by Wellmark.

Drugs that are Covered The Wellmark Blue Rx Value Plus

Drug List

The Wellmark Blue Rx Value Plus Drug List

is a reference list that includes generic and

brand-name prescription drugs and


devices that have been approved by the U.S.

Food and Drug Administration (FDA) and

are covered under your Blue Rx Value Plus

prescription drug benefits. The Wellmark

Blue Rx Value Plus Drug List is established

and maintained by Wellmark’s Pharmacy &

Therapeutics (P&T) Committee. The P&T

Committee is an independent group of

practicing healthcare providers such as

physicians and pharmacists who regularly

meet to review the safety, effectiveness, and

value of new and existing medications and

make any necessary changes to the Drug

List. The Drug List is updated on a quarterly

basis. Changes to the Drug List may occur

more frequently, when new versions or

generic versions of existing drugs become

available, new safety concerns arise, and as

discontinued drugs are removed from the

marketplace. Additional changes to the

Drug List that could have an adverse

financial impact to you (e.g., drug exclusion,



drug moving to a higher payment tier/level)

occur semi-annually.

To determine if a drug is covered, you must

consult the Wellmark Blue Rx Value Plus

Drug List. You are covered for drugs listed

on the Wellmark Blue Rx Value Plus Drug

List. If a drug is not on the Wellmark Blue

Rx Value Plus Drug List, it is not covered.

If you need help determining if a particular

drug is on the Drug List, ask your physician

or pharmacist, visit our website,

Wellmark.com, or call the Customer Service

number on your ID card and request a copy

of the Drug List.

The Drug List is subject to change.

Preventive Items and Services Preventive items and services received at a

licensed retail pharmacy, including certain

items or services recommended with an “A”

or “B” rating by the United States Preventive

Services Task Force, immunizations

recommended by the Advisory Committee

on Immunization Practices of the Centers

for Disease Control and Prevention, and

preventive care and screenings provided for

in guidelines supported by the Health

Resources and Services Administration are

covered. To determine if a particular

preventive item or service is covered,


Drug List or call the Customer Service


Specialty Drugs Specialty drugs are high-cost injectable,

oral, or inhaled drugs typically used for

treating or managing chronic illnesses.

These drugs often require special handling

(e.g., refrigeration) and administration. You

must purchase specialty drugs through the

specialty pharmacy program. They are not

available through the mail order drug

program.

Specialty drugs may be covered under your


benefits or under your medical benefits. To

determine whether a particular specialty

drug is covered under your Blue Rx Value

Plus prescription drug benefits or under

your medical benefits, consult the Wellmark

Blue Rx Value Plus Drug List at

Wellmark.com, check with your pharmacist

or physician, or call the Customer Service

number on your ID card. See Specialty

Drugs, page 52.

Nicotine Dependency Drugs Prescription drugs and devices used to treat

nicotine dependence, including over-the-

counter drugs prescribed by a physician are

covered.

Benefits Maximum: 180-days' supply of

covered over-the-counter drugs for smoking

cessation per calendar year.

Where to Purchase Prescription Drugs Specialty Drugs. You must purchase

specialty drugs through UI Healthcare

Specialty Pharmacy. If you purchase

specialty drugs outside UI Healthcare

Specialty Pharmacy, you are responsible for

the entire cost of the drug. See Specialty

Drugs, page 52.

Limits on Prescription Drug Coverage We may exclude, discontinue, or limit

coverage for any drug by removing it from

the Drug List or by moving a drug to a

different tier on the Drug List for any of the

following reasons:

◼ New drugs are developed.

◼ Generic drugs become available.

◼ Over-the-counter drugs with similar

properties become available or a drug’s

active ingredient is available in a similar

strength in an over-the-counter product

or as a nutritional or dietary supplement

product available over the counter.

◼ There is a sound medical reason.

◼ Scientific evidence does not show that a

drug works as well and is as safe as other

drugs used to treat the same or similar

conditions.



◼ A drug receives FDA approval for a new

use.

Drugs, Services, and Items that are Not Covered Drugs, services, and items that are not

covered under your prescription drug

benefits include, but are not limited to:

◼ Drugs not listed on the Wellmark Blue

Rx Value Plus Drug List.

◼ Specialty drugs purchased outside the

specialty pharmacy program unless the

specialty drug is covered under your

medical benefits.

◼ Drugs in excess of a quantity limitation.

See Quantity Limitations later in this

section.

◼ Antigen therapy.

◼ Drugs that are not FDA-approved.

◼ Drugs that are not approved to be

covered by Wellmark’s P&T Committee.

◼ Investigational or experimental drugs.

◼ Compounded drugs that do not contain

an active ingredient in a form that has

been approved by the FDA and that

require a prescription to obtain.

◼ Compounded drugs that contain bulk

powders or that are commercially

available as a similar prescription drug.

◼ Drugs determined to be abused or

otherwise misused by you.

◼ Drugs that are lost, damaged, stolen, or

used inappropriately.

◼ Contraceptive medical devices, such as

intrauterine devices and diaphragms.

These are covered under your medical

benefits. See Contraceptives, page 19.

◼ Convenience packaging. If the cost of

the convenience packaged drug exceeds

what the drug would cost if purchased in

its normal container, the convenience

packaged drug is not covered.

◼ Cosmetic drugs.

◼ Infused drugs. These may be covered

under your medical benefits. See

Specialty Drugs, page 29.

◼ Irrigation solutions and supplies.

◼ Medication Therapy Management

(MTM) when billed separately.

◼ Therapeutic devices or medical

appliances.

◼ Infertility drugs.

◼ Weight reduction drugs.






equivalent.

See Also:


Prescription Purchases Outside the United States To qualify for benefits for prescription drugs

purchased outside the United States, all of

the following requirements must be met:

◼ You are injured or become ill while in a

foreign country.

◼ The prescription drug's active ingredient

and dosage form are FDA-approved or

an FDA equivalent and has the same

name and dosage form as the FDA-

approved drug's active ingredient.

◼ The prescription drug would require a

written prescription by a licensed

practitioner if prescribed in the U.S.

◼ You provide acceptable documentation

that you received a covered service from

a practitioner or hospital and the

practitioner or hospital prescribed the

prescription drug.

Quantity Limitations Most prescription drugs are limited to a

maximum quantity you may receive in a

single prescription.

Federal regulations limit the quantity that

may be dispensed for certain medications. If

your prescription is so regulated, it may not

be available in the amount prescribed by

your physician.

In addition, coverage for certain drugs is

limited to specific quantities per month,



benefit year, or lifetime. Amounts in excess

of quantity limitations are not covered.

For a list of drugs with quantity limits,

check with your pharmacist or physician,


Drug List at Wellmark.com, or call the

Customer Service number on your ID card.

Refills To qualify for refill benefits, all of the

following requirements must be met:

◼ Sufficient time has elapsed since the last

prescription was written. Sufficient time

means that at least 75 percent of the

medication has been taken according to

the instructions given by the

practitioner.

◼ The refill is not to replace medications

that have been lost, damaged, stolen, or

used inappropriately.

◼ The refill is for use by the person for

whom the prescription is written (and

not someone else).

◼ The refill does not exceed the amount

authorized by your practitioner.

◼ The refill is not limited by state law.

You are allowed one early refill per

medication per calendar year if you will be

away from home for an extended period of

time.

If traveling within the United States, the

refill amount will be subject to any

applicable quantity limits under this

coverage. If traveling outside the United

States, the refill amount will not exceed a

90-day supply.

To receive authorization for an early refill,

ask your pharmacist to call us.

Form Number: Wellmark IA Grp/GC_ 0121 39 WEB T94

4. General Conditions of Coverage, Exclusions, and Limitations

The provisions in this section describe

general conditions of coverage and

important exclusions and limitations that

apply generally to all types of services or

supplies.

Conditions of Coverage

Medically Necessary A key general condition in order for you to

receive benefits is that the service, supply,

device, or drug must be medically necessary.

Even a service, supply, device, or drug listed

as otherwise covered in Details - Covered

and Not Covered may be excluded if it is not

medically necessary in the circumstances.

Unless otherwise required by law, Wellmark

determines whether a service, supply,

device, or drug is medically necessary, and

that decision is final and conclusive.

Wellmark’s medically necessary analysis

and determinations apply to any service,

supply, device, or drug including, but not

limited to, medical, mental health, and

chemical dependency treatment, as

appropriate. Even though a provider may

recommend a service or supply, it may not

be medically necessary.

A medically necessary health care service is

one that a provider, exercising prudent

clinical judgment, provides to a patient for

the purpose of preventing, evaluating,

diagnosing or treating an illness, injury,

disease or its symptoms, and satisfies all of

the following criteria:

◼ Provided in accordance with generally

accepted standards of medical practice.

Generally accepted standards of medical

practice are based on:

⎯ Nationally recognized utilization

management standards as utilized

by Wellmark; or

⎯ Wellmark’s published Medical and

Drug Policies as determined

applicable by Wellmark; or

⎯ Credible scientific evidence

published in peer-reviewed medical

literature generally recognized by

the relevant medical community; or

⎯ Physician Specialty Society

recommendations and the views of

physicians practicing in the relevant

clinical area.

◼ Clinically appropriate in terms of type,

frequency, extent, site and duration, and

considered effective for the patient’s

illness, injury or disease,

◼ Not provided primarily for the

convenience of the patient, physician, or

other health care provider, and

◼ Not more costly than an alternative

service or sequence of services at least as

likely to produce equivalent therapeutic

or diagnostic results as to the diagnosis

or treatment of the illness, injury or

disease.

An alternative service, supply, device, or

drug may meet the criteria of medical

necessity for a specific condition. If

alternatives are substantially equal in

clinical effectiveness and use similar

therapeutic agents or regimens, we reserve

the right to approve the least costly

alternative.

If you receive services that are not medically

necessary, you are responsible for the cost

if:

◼ You receive the services from an Out-of-

Network Provider; or

◼ You receive the services from a Network

or Participating provider and:

⎯ The provider informs you in writing

before rendering the services that

Wellmark determined the services to

be not medically necessary; and

General Conditions of Coverage, Exclusions, and Limitations

WEB T94 40 Form Number: Wellmark IA Grp/GC_ 0121

⎯ The provider gives you a written

estimate of the cost for such services

and you agree in writing, before

receiving the services, to assume the

payment responsibility.

If you do not receive such a written

notice, and do not agree in writing to

assume the payment responsibility for

services that Wellmark determined are

not medically necessary, the Network or

Participating provider is responsible for

these amounts.

◼ You are also responsible for the cost if

you receive services from an Out-of-

Network Provider that Wellmark

determines to be not medically

necessary. This is true even if the

provider does not give you any written

notice before the services are rendered.

Member Eligibility Another general condition of coverage is

that the person who receives services must

meet requirements for member eligibility.

See Coverage Eligibility and Effective Date,

page 67.

General Exclusions Even if a service, supply, device, or drug is

listed as otherwise covered in Details -

Covered and Not Covered, it is not eligible

for benefits if any of the following general

exclusions apply.

Investigational or Experimental You are not covered for a service, supply,

device, biological product, or drug that is

investigational or experimental. You are

also not covered for any care or treatments

related to the use of a service, supply,

device, biological product, or drug that is

investigational or experimental. A treatment

is considered investigational or

experimental when it has progressed to

limited human application but has not

achieved recognition as being proven

effective in clinical medicine. Our analysis of

whether a service, supply, device, biological

product, or drug is considered

investigational or experimental is applied to

medical, surgical, mental health, and

chemical dependency treatment services, as

applicable.

To determine investigational or

experimental status, we may refer to the

technical criteria established by the Blue

Cross Blue Shield Association, including

whether a service, supply, device, biological

product, or drug meets these criteria:

◼ It has final approval from the

appropriate governmental regulatory

bodies.

◼ The scientific evidence must permit

conclusions concerning its effect on

health outcomes.

◼ It improves the net health outcome.

◼ It is as beneficial as any established

alternatives.

◼ The health improvement is attainable

outside the investigational setting.

These criteria are considered by the Blue

Cross Blue Shield Association's Medical

Advisory Panel for consideration by all Blue

Cross and Blue Shield member

organizations. While we may rely on these

criteria, the final decision remains at the

discretion of our Medical Director, whose

decision may include reference to, but is not

controlled by, policies or decisions of other

Blue Cross and Blue Shield member

organizations. You may access our medical

policies, with supporting information and

selected medical references for a specific

service, supply, device, biological product,

or drug through our website,

Wellmark.com.

If you receive services that are

investigational or experimental, you are

responsible for the cost if:

◼ You receive the services from an Out-of-

Network Provider; or

◼ You receive the services from a Network

or Participating provider and:

⎯ The provider informs you in writing

before rendering the services that

Wellmark determined the services to



be investigational or experimental;

and

⎯ The provider gives you a written

estimate of the cost for such services

and you agree in writing, before

receiving the services, to assume the

payment responsibility.

If you do not receive such a written

notice, and do not agree in writing to

assume the payment responsibility for

services that Wellmark determined to be

investigational or experimental, the

Network or Participating provider is

responsible for these amounts.

◼ You are also responsible for the cost if


Network Provider that Wellmark

determines to be investigational or

experimental. This is true even if the

provider does not give you any written

notice before the services are rendered.

See Also:

Clinical Trials, page 19.

Complications of a Noncovered Service You are not covered for a complication

resulting from a noncovered service, supply,

device, or drug. However, this exclusion

does not apply to the treatment of

complications resulting from:

◼ Smallpox vaccinations when payment

for such treatment is not available

through workers’ compensation or

government-sponsored programs; or

◼ A noncovered abortion.

Nonmedical or Administrative Services You are not covered for telephone

consultations, charges for failure to keep

scheduled appointments, charges for

completion of any form, charges for medical

information, recreational therapy and other

sensory-type activities, administrative

services (such as interpretive services, pre-

care assessments, health risk assessments,

case management, care coordination, or

development of treatment plans) when

billed separately, and any services or

supplies that are nonmedical.

Provider Is Family Member You are not covered for a service or supply

received from a provider who is in your

immediate family (which includes yourself,

parent, child, or spouse or domestic

partner).

Covered by Other Programs or Laws You are not covered for a service, supply,

device, or drug if:

◼ Someone else has the legal obligation to

pay for services, has an agreement with

you to not submit claims for services or,

without this group health plan, you

would not be charged.

◼ You require services or supplies for an

illness or injury sustained while on

active military status.

Workers’ Compensation You are not covered for services or supplies

for which we learn or are notified by you,

your provider, or our vendor that such

services or supplies are related to a work

related illness or injury, including services

or supplies applied toward satisfaction of

any deductible under your employer’s

workers’ compensation coverage. We will

comply with our statutory obligation

regarding payment on claims on which

workers’ compensation liability is

unresolved. You are also not covered for any

services or supplies that could have been

compensated under workers’ compensation

laws if:

◼ you did not comply with the legal

requirements relating to notice of injury,

timely filing of claims, and medical

treatment authorization; or

◼ you rejected workers’ compensation

coverage.

The exclusion for services or supplies

related to work related illness or injury does

not exclude coverage for such illness or

injury if you are exempt from coverage

under Iowa’s workers’ compensation

statutes pursuant to Iowa Code Section 85.1


WEB T94 42 Form Number: Wellmark IA Grp/GC_ 0121

(1)-(4), unless you or your employer has

elected or obtained workers’ compensation

coverage as provided in Iowa Code Section

85.1(6).

For treatment of complications resulting

from smallpox vaccinations, see

Complications of a Noncovered Service

earlier in this section.

Wellmark Medical and Drug Policies Wellmark maintains Medical and Drug

Policies that are applied in conjunction with

other resources to determine whether a

specific service, supply, device, biological

product, or drug is a covered service under

the terms of this coverage manual. These

policies are hereby incorporated into this

coverage manual. You may access these

policies along with supporting information

and selected medical references through our

website, Wellmark.com.

Benefit Limitations Benefit limitations refer to amounts for

which you are responsible under this group

health plan. These amounts are not credited

toward your out-of-pocket maximum. In

addition to the exclusions and conditions

described earlier, the following are

examples of benefit limitations under this

group health plan:

◼ A service or supply that is not covered

under this group health plan is your

responsibility.

◼ If a covered service or supply reaches a

benefits maximum, it is no longer

eligible for benefits. (A maximum may

renew at the next benefit year.) See

Details – Covered and Not Covered,

page 17.

◼ If you receive benefits that reach a

lifetime benefits maximum applicable to

any specific service, then you are no

longer eligible for benefits for that

service under this group health plan. See

Benefits Maximums, page 9, and At a

Glance–Covered and Not Covered, page

13.

◼ If you do not obtain precertification for

certain medical services, benefits can be

denied. You are responsible for benefit

denials only if you are responsible (not

your provider) for notification. A

Network Provider in the Wellmark Blue

HMO network will handle notification

requirements for you. If you see a

provider outside the Wellmark Blue

HMO network, you are responsible for

notification requirements. See



◼ If you do not obtain prior approval for

certain medical services, benefits will be

denied on the basis that you did not

obtain prior approval. Upon receiving an

Explanation of Benefits (EOB)

indicating a denial of benefits for failure

to request prior approval, you will have

the opportunity to appeal (see the

Appeals section) and provide us with

medical information for our

consideration in determining whether

the services were medically necessary

and a benefit under your medical

benefits. Upon review, if we determine

the service was medically necessary and

a benefit under your medical benefits,

benefits for that service will be provided

according to the terms of your medical

benefits.

You are responsible for these benefit

denials only if you are responsible (not

your provider) for notification. A

Network Provider in the Wellmark Blue

HMO network will handle notification

requirements for you. If you see a

provider outside the Wellmark Blue

HMO network, you are responsible for

notification requirements. See



◼ If you do not obtain prior authorization

for certain prescription drugs, benefits

can be denied. See Notification

Requirements and Care Coordination,

page 53.



◼ The type of provider you choose can

affect your benefits and what you pay.

See Choosing a Provider, page 45, and

Factors Affecting What You Pay, page

59. An example of a charge that depends

on the type of provider includes, but is

not limited to:

⎯ Any difference between the

provider’s amount charged and our

amount paid is your responsibility if


Network practitioner.

Form Number: Wellmark IA Grp/CP_ 0121 45 WEB T94

5. Choosing a Provider

Medical

Provider Network Under the medical benefits of this plan,

your network of providers consists of

domestic providers and Wellmark Blue

HMO Providers. All other providers are not

in your network. Which provider type you

choose will affect what you pay.

Providers who do not participate with the

network utilized by these medical benefits

are called Out-of-Network Providers.

Benefits for most covered services are

available only when received from Network

Providers.

To determine if a provider participates with

this medical benefits plan, ask your

provider, refer to our online provider

directory at Wellmark.com, or call the


Our provider directory is also available upon

request by calling the Customer Service


Providers are independent contractors and

are not agents or employees of Wellmark

Health Plan of Iowa, Inc. For types of

providers that may be covered under your

medical benefits, see Hospitals and

Facilities, page 24 and Physicians and

Practitioners, page 28.

Please note: Even if a specific provider

type is not listed as a recognized provider

type, Wellmark does not discriminate

against a licensed health care provider

acting within the scope of his or her state

license or certification with respect to

coverage under this plan.

Please note: Even though a facility may be

a Wellmark Blue HMO network facility,

particular providers within the facility may

not be Wellmark Blue HMO Providers.

Examples include Out-of-Network

physicians on the staff of a Wellmark Blue

HMO network hospital, home medical

equipment suppliers, and other

independent providers. Therefore, when you

are referred by a Wellmark Blue HMO

Provider to another provider, or when you

are admitted into a facility, always ask if the

providers are Wellmark Blue HMO

Providers.

Always carry your ID card and present it

when you receive services. Information on

it, especially the ID number, is required to

process your claims correctly.

Pharmacies that contract with our

pharmacy benefits manager are considered

Participating Providers. Pharmacies that do

not contract with our pharmacy benefits

manager are considered Out-of-Network

Providers. To determine if a pharmacy

contracts with our pharmacy benefits

manager, ask the pharmacist, consult the

directory of participating pharmacies on our

website at Wellmark.com, or call the


See Choosing a Pharmacy and Specialty

Drugs later in this section.

Blue Distinction Centers Blue Distinction Centers (BDC) met overall

quality measures, developed with input

from the medical community. A local Blue

Plan may require additional criteria for

providers located in its own service area; for

details, contact your local Blue Plan. Blue

Distinction Centers+ (BDC+) also met cost

measures that address consumers’ need for

affordable healthcare. Each provider’s cost

of care is evaluated using data from its local

Blue Plan. Providers in California, Idaho,

New York, Pennsylvania, and Washington

may lie in two local Blue Plans’ areas,

resulting in two evaluations for cost of care;

and their own local Blue Plans decide

whether one or both cost of care

evaluation(s) must meet BDC+ national

Choosing a Provider

WEB T94 46 Form Number: Wellmark IA Grp/CP_ 0121

criteria. National criteria for BDC and BDC+

are displayed on www.bcbs.com. Individual

outcomes may vary. For details on a

provider’s in-network status or your own

coverage, contact your local Blue Plan and

ask your provider before making an

appointment. Neither Blue Cross and Blue

Shield Association nor any Blue Plans are

responsible for noncovered charges or other

losses or damages resulting from Blue

Distinction or other provider finder

information or care received from Blue

Distinction or other providers.

Referrals If there are no providers in the Wellmark

Blue HMO network who can treat your

condition, you will be referred to a provider

outside the Wellmark Blue HMO network

who has expertise in diagnosing and

treating your condition. Wellmark must

approve referrals outside of the Wellmark

Blue HMO network before you receive

services or the services will not be covered.

Please note: Even when your referral

outside the Wellmark Blue HMO network is

approved, you are still responsible for

complying with notification requirements.

See Notification Requirements and Care

Coordination, page 53. Please note: Even

when your referral outside the Wellmark

Blue HMO network is approved, you may be

responsible for the difference between the

amount an Out-of-Network Provider bills

and our payment amount.

Services Outside the Wellmark Blue HMO Network

BlueCard Program This program ensures that members of any

Blue Plan have access to the advantages of

Participating Providers throughout the

United States. Participating Providers have

a contractual arrangement with the Blue

Cross or Blue Shield Plan in their home

state (“Host Blue”). The Host Blue is

responsible for contracting with and

generally handling all interactions with its

Participating Providers.

The BlueCard Program is one of the

advantages of your coverage with Wellmark

Health Plan of Iowa, Inc. It provides

conveniences and benefits outside the

Wellmark Blue HMO network area for

emergency care or accidental injury similar

to those you would have in the Wellmark

Blue HMO network area when you obtain

covered medical services from a Network

Provider. Always carry your ID card (or

BlueCard) and present it to your provider

when you receive care. Information on it,

especially the ID number, is required to

process your claims correctly.

In an emergency situation, seek care at the

nearest hospital emergency room.

Whenever possible, before receiving services

outside the Wellmark Blue HMO network,

you should always ask the provider if he or

she participates with a Blue Cross and/or

Blue Shield Plan in that state. To locate

Participating Providers in any state, call

800-810-BLUE, or visit www.bcbs.com.

When you receive covered services from

Participating Providers outside the

Wellmark Blue HMO network, all of the

following statements are true:

◼ Claims are filed for you.

◼ These providers agree to accept payment

arrangements or negotiated prices of the

Blue Cross and/or Blue Shield Plan with

which the provider contracts. These

payment arrangements may result in

savings.

◼ The group health plan payment is sent

directly to the providers.

◼ Wellmark requires claims to be filed

within 180 days following the date of

service. However, if the Participating

Provider’s contract with the Host Blue

has a requirement that a claim be filed

in a timeframe exceeding 180 days

following the date of service, Wellmark

will process the claim according to the

Host Blue’s contractual filing

requirement. If you receive services

http://www.bcbs.com/

http://www.bcbs.com/

Choosing a Provider


from an Out-of-Network Provider, the

claim has to be filed within 180 days

following the date of service.

Typically, when you receive covered services

from Participating Providers outside the

Wellmark Blue HMO network, you are

responsible for notification requirements.

See Notification Requirements and Care

Coordination, page 53. However, if you are

admitted to a BlueCard facility outside the

Wellmark Blue HMO network, any

Participating Provider should handle

notification requirements for you.

Wellmark Health Plan of Iowa, Inc., is an

affiliate of Wellmark, Inc., doing business as

Wellmark Blue Cross and Blue Shield of

Iowa, independent licensees of the Blue

Cross Blue Shield Association. We have a

variety of relationships with other Blue

Cross and/or Blue Shield Plans and their

Licensed Controlled Affiliates (“Licensees”).

Generally, these relationships are called

“Inter-Plan Arrangements.” These Inter-

Plan Arrangements work based on rules and

procedures issued by the Blue Cross Blue

Shield Association (“Association”).

Whenever you obtain healthcare services

outside the Wellmark Blue HMO network,

the claims for these services may be

processed through one of these Inter-Plan

Arrangements.

When you receive care outside of our service

area, you will receive it from one of two

kinds of providers. Most providers

(“Participating Providers”) contract with the

local Blue Cross and/or Blue Shield Plan in

that geographic area (“Host Blue”). Some

providers (“Out-of-Network Providers”)

don’t contract with the Host Blue. In the

following paragraphs we explain how we

pay both kinds of providers.

We cover only limited healthcare services

received outside of our service area. As used

in this section, “out-of-area covered

services” include accidental injuries,

emergencies, continuity of care, out-of-

network referrals, and Guest Membership

obtained outside the geographic area we

serve. Any other services will not be covered

when processed through any Inter-Plan

Arrangements, unless authorized by us.

Inter-Plan Arrangements Eligibility – Claim Types All claim types are eligible to be processed

through Inter-Plan Arrangements, as

described previously, except for all dental

care benefits (except when paid as medical

benefits), and those prescription drug

benefits or vision care benefits that may be

administered by a third party contracted by

us to provide the specific service or services.

BlueCard® Program Under the BlueCard® Program, when you

receive out-of-area covered services within

the geographic area served by a Host Blue,

we will remain responsible for doing what

we agreed to in the contract. However, the

Host Blue is responsible for contracting

with and generally handling all interactions

with its Participating Providers.

The BlueCard Program enables you to

obtain covered out-of-area services, as

defined previously in this section, from a

healthcare provider participating with a

Host Blue, where available. The

Participating Provider will automatically file

a claim for the covered out-of-area services

provided to you, so there are no claim forms

for you to fill out. You will be responsible for

your payment obligations. See Referrals

earlier in this section. In addition

notification requirements may apply, See



Emergency Care Services: If you

experience a medical emergency while

traveling outside the Wellmark Blue HMO

network, go to the nearest emergency or

urgent care facility.

When you receive covered out-of-area

services outside our service area and the

claim is processed through the BlueCard

Program, the amount you pay for the

covered out-of-area services, if not a flat

dollar copayment, is calculated based on the

lower of:

Choosing a Provider


◼ The billed charges for your out-of-area

covered services; or

◼ The negotiated price that the Host Blue

makes available to us.

Often, this “negotiated price” will be a

simple discount that reflects an actual price

that the Host Blue pays to your healthcare

provider. Sometimes, it is an estimated

price that takes into account special

arrangements with your healthcare provider

or provider group that may include types of

settlements, incentive payments and/or

other credits or charges. Occasionally, it

may be an average price, based on a

discount that results in expected average

savings for similar types of healthcare

providers after taking into account the same

types of transactions as with an estimated

price.

Estimated pricing and average pricing also

take into account adjustments to correct for

over- or underestimation of modifications of

past pricing of claims, as noted previously.

However, such adjustments will not affect

the price we have used for your claim

because they will not be applied after a

claim has already been paid.

Inter-Plan Programs: Federal/State Taxes/Surcharges/Fees Federal or state laws or regulations may

require a surcharge, tax, or other fee that

applies to insured accounts. If applicable,

we will include any such surcharge, tax, or

other fee as part of the claim charge passed

on to you.

Out-of-Network Providers Outside the Wellmark Service Area Your Liability Calculation. When

covered out-of-area services are provided

outside of our service area by Out-of-

Network Providers, the amount you pay for

such services will normally be based on

either the Host Blue’s Out-of-Network

Provider local payment or the pricing

arrangements required by applicable state

law. In these situations, you may be

responsible for the difference between the

amount that the Out-of-Network Provider

bills and the payment we will make for the

covered out-of-area services as set forth in

this coverage manual. Federal or state law,

as applicable, will govern payments for Out-

of-Network emergency services.

In certain situations, we may use other

payment methods, such as billed charges for

covered out-of-area services, the payment

we would make if the healthcare services

had been obtained within our service area,

or a special negotiated payment to

determine the amount we will pay for

services provided by Out-of-Network

Providers. In these situations, you may be

liable for the difference between the amount

that the Out-of-Network Provider bills and

the payment we will make for the covered

out-of-area services as set forth in this

coverage manual.

Change of Residence You must notify us prior to relocating

outside the Wellmark Health Plan of Iowa,

Inc., geographic service area because you

will have no benefits for medical or

laboratory services provided outside of

Wellmark Health Plan of Iowa, Inc.’s

provider network except for emergencies or

accidental injuries.

Care in a Foreign Country For covered services you receive in a

country other than the United States,

payment level assumes the provider

category is Out-of-Network except for

services received from providers that

participate with Blue Cross Blue Shield

Global Core. You are only covered for

emergency care or care for an accidental

injury when you receive care in a foreign

country.

Blue Cross Blue Shield Global® Core Program If you are outside the United States, the

Commonwealth of Puerto Rico, and the U.S.

Virgin Islands, you may be able to take

advantage of the Blue Cross Blue Shield

Global Core Program when accessing

covered services. The Blue Cross Blue Shield

Global Core Program is unlike the BlueCard

Choosing a Provider


Program available in the United States, the


Virgin Islands in certain ways. For instance,

although the Blue Cross Blue Shield Global

Core Program assists you with accessing a

network of inpatient, outpatient, and

professional providers, the network is not

served by a Host Blue. As such, when you

receive care from providers outside the

United States, the Commonwealth of Puerto

Rico, and the U.S. Virgin Islands, you will

typically have to pay the providers and

submit the claims yourself to obtain

reimbursement for these services.

If you need medical assistance services

(including locating a doctor or hospital)

outside the United States, the


Virgin Islands, you should call the Blue

Cross Blue Shield Global Core Service

Center at 800-810-BLUE (2583) or call

collect at 804-673-1177, 24 hours a day,

seven days a week. An assistance

coordinator, working with a medical

professional, can arrange a physician

appointment or hospitalization, if necessary.

Inpatient Services. In most cases, if you

contact the Blue Cross Blue Shield Global

Core Service Center for assistance, hospitals

will not require you to pay for covered

inpatient services, except for your

deductibles, coinsurance, etc. In such cases,

the hospital will submit your claims to the

Blue Cross Blue Shield Global Core Service

Center to begin claims processing. However,

if you paid in full at the time of service, you

must submit a claim to receive

reimbursement for covered services. You

must contact us to obtain

precertification for non-emergency

inpatient services.

Outpatient Services. Physicians, urgent

care centers and other outpatient providers

located outside the United States, the


Virgin Islands will typically require you to

pay in full at the time of service. You must

submit a claim to obtain reimbursement for

covered services. See Claims, page 77.

Submitting a Blue Cross Blue Shield Global Core Claim When you pay for covered services outside

the United States, the Commonwealth of

Puerto Rico, and the U.S. Virgin Islands,

you must submit a claim to obtain

reimbursement. For institutional and

professional claims, you should complete a

Blue Cross Blue Shield Global Core

International claim form and send the claim

form with the provider’s itemized bill(s) to

the Blue Cross Blue Shield Global Core

Service Center (the address is on the form)

to initiate claims processing. Following the

instructions on the claim form will help

ensure timely processing of your claim. The

claim form is available from us, the Blue

Cross Blue Shield Global Core Service

Center, or online at

www.bcbsglobalcore.com. If you need

assistance with your claim submission, you

should call the Blue Cross Blue Shield

Global Core Service Center at 800-810-

BLUE (2583) or call collect at 804-673-

1177, 24 hours a day, seven days a week.

You are eligible for benefits for covered

services received from Out-of-Network or

Participating providers (including out-of-

country providers) only in the following

situations:

◼ Accidental Injuries.

◼ Emergencies.

If you are unable to reach a Network

Provider, it is usually to your advantage

to receive services from a Participating

Provider. Participating Providers

participate with a Blue Cross and/or

Blue Shield Plan, but not with the

Wellmark Blue HMO network.

Out-of-Network Providers do not

participate with this plan or any other

Blue Cross and/or Blue Shield Plan.

For information on how benefits for

accidental injuries and emergency

services will be administered when

received outside of the Wellmark Blue

HMO network, see BlueCard Program

http://www.bcbsglobalcore.com/

Choosing a Provider


earlier in this section and Out-of-

Network Providers, page 61.

When you receive covered services for

emergency medical conditions from

Out-of-Network Providers, all of the

following statements are true:

⎯ Out-of-Network Providers are not

responsible for filing your claims.

⎯ We do not have contracts with Out-

of-Network Providers and they may

not agree to accept our payment

arrangements. Therefore, you are

responsible for any difference

between the amount charged and

our payment.

⎯ We make claims payments to you,

not Out-of-Network Providers.

⎯ You are responsible for notification

requirements.

◼ Continuity of Care. You may be

eligible to continue care from an Out-of-

Network Provider for treatment of a

terminal illness, a complex medical

condition, or during the second or third

trimester of pregnancy if:

⎯ You had been receiving care for the

condition from a Network Provider

but the provider’s contract with us

terminates; or

⎯ You were previously covered by a

different carrier or plan and had

been receiving care for the condition

from an Out-of-Network Provider

when you begin coverage under your

medical benefits.

If either situation applies, you may

continue Out-of-Network treatment as

follows:

⎯ Terminal illness (as determined by

the provider): for 90 days after the

provider’s contract terminates or the

patient begins coverage with

Wellmark while under the care of an

Out-of-Network Provider for

treatment of the terminal illness,

whichever applies.

⎯ Complex medical condition: for a

time period or benefit maximum

determined by medical

management. You or your provider

must notify us before receiving

services under these medical

benefits, and the medical condition

must warrant continued treatment

by the Out-of-Network Provider.

⎯ Pregnancy in second or third

trimester: through postpartum care

related to the childbirth and

delivery.

To assist you in making a transition to a

Network Provider, you or your provider

must call us at 800-552-3993.

◼ Referrals. See Referrals earlier in this

section.

Guest Membership. Members traveling

long-term, any covered dependents

attending college out of state, or covered

family members living apart are eligible to

become a guest member any time they are

outside the Wellmark Blue HMO network

area for at least 90 days. Not all services

covered under your medical benefits are

covered under Guest Membership. To

determine which services are covered under

the Guest Membership program, call us.

To receive covered services under the Guest

Membership program, you must receive the

service(s) from a Participating Provider.

Before you leave the Wellmark Blue HMO

network area, call the Customer Service

number on your ID card to set up a guest

membership.

Laboratory services. You may have

laboratory specimens or samples collected

by a Network Provider and those laboratory

specimens may be sent to another

laboratory services provider for processing

or testing. If that laboratory services

provider does not have a contractual

relationship with the Blue Plan where the

specimen was drawn,* the service will not

be covered and you will be responsible for

the entire amount charged.

*Where the specimen is drawn will be

determined by which state the referring

provider is located.

Choosing a Provider


Home/durable medical equipment. If

you purchase or rent home/durable medical

equipment from a provider that does not

have a contractual relationship with the

Blue Plan where you purchased or rented

the equipment, the service will not be

covered and you will be responsible for the

entire amount charged.

If you purchase or rent home/durable

medical equipment and have that

equipment shipped to a service area of a

Blue Plan that does not have a contractual

relationship with the home/durable medical

equipment provider, the service will not be


entire amount charged. This includes

situations where you purchase or rent

home/durable medical equipment and have

the equipment shipped to you in the

Wellmark Blue HMO network, when

Wellmark does not have a contractual

relationship with the home/durable medical

equipment provider.

Prosthetic devices. If you purchase

prosthetic devices from a provider that does

not have a contractual relationship with the

Blue Plan where you purchased the

prosthetic devices, the service will not be


entire amount charged.

If you purchase prosthetic devices and have

that equipment shipped to a service area of

a Blue Plan that does not have a contractual

relationship with the provider, the service

will not be covered and you will be

responsible for the entire amount charged.

This includes situations where you purchase

prosthetic devices and have them shipped to

you in the Wellmark Blue HMO network,

when Wellmark does not have a contractual

relationship with the provider.

Talk to your provider. Whenever

possible, before receiving laboratory

services, home/durable medical equipment,

or prosthetic devices, ask your provider to

utilize a provider that has a contractual

arrangement with the Blue Plan where you

received services, purchased or rented

equipment, or shipped equipment, or ask

your provider to utilize a provider that has a

contractual arrangement with Wellmark.

To determine if a provider has a contractual

arrangement with a particular Blue Plan or

with Wellmark, call the Customer Service

number on your ID card or visit our website,

Wellmark.com.

See Out-of-Network Providers, page 61.

Prescription Drugs

Choosing a Pharmacy Your prescription drug benefits are called

Blue Rx Value Plus. Pharmacies that

participate with the network used by Blue

Rx Value Plus are called participating

pharmacies. Pharmacies that do not

participate with the network are called

nonparticipating pharmacies.

To determine if a pharmacy is participating,

ask the pharmacist, consult the directory of

participating pharmacies on our website at


number on your ID card. Our directory also

is available upon request by calling the


Blue Rx Value Plus allows you to purchase

most covered prescription drugs from

almost any pharmacy you choose. However,

you will usually pay more for prescription

drugs when you purchase them from

nonparticipating pharmacies. Remember,

you are responsible for the entire cost if you

purchase a drug that is not on the Wellmark

Drug List. We recommend you:

◼ Fill your prescriptions at a participating

retail pharmacy, or through the mail

order drug program. See Mail Order

Drug Program and Specialty Drugs


Choosing a Provider


◼ Fill your specialty drugs through UI

Healthcare Specialty Pharmacy. See

Specialty Drugs later in this section.

◼ Advise your physician that you are

covered under Blue Rx Value Plus.

◼ Always present your ID card when filling

prescriptions. Your ID card enables

participating pharmacists to access your

benefits information.

Advantages of Visiting Participating Pharmacies When you fill your prescription at

participating pharmacies:

◼ You will usually pay less. If you use a

nonparticipating pharmacy, you must

pay the amount charged at the time of

purchase, and the amount we reimburse

you may be less than what you paid. You

are responsible for this difference.

◼ The participating pharmacist can check

whether your prescription is subject to

prior authorization or quantity limits.

◼ The participating pharmacist can access

your benefit information, verify your

eligibility, check whether the

prescription is a benefit under your Blue

Rx Value Plus prescription drug

benefits, list the amount you are

expected to pay, and suggest generic

alternatives.

Always Present Your ID Card If you do not have your ID card with you

when you fill a prescription at a

participating pharmacy, the pharmacist may

not be able to access your benefit

information. In this case:

◼ You must pay the full amount charged at

the time you receive your prescription,

and the amount we reimburse you may

be less than what you paid. You are

responsible for this difference.

◼ You must file your claim to be

reimbursed. See Claims, page 77.

Specialty Drugs You must purchase specialty drugs through

UI Healthcare Specialty Pharmacy.

You are not covered for specialty drugs

purchased outside UI Healthcare Specialty

Pharmacy unless the specialty drug is

covered under your medical benefits.

Mail Order Drug Program When you fill your prescription through the

mail order drug program, you will usually

pay less than if you use a nonparticipating

mail order pharmacy.

You must register as a mail service user in

order to fill your prescriptions through the

mail order drug program. For information

on how to register, visit our website,



Mail order pharmacy providers outside our

mail order program are considered

nonparticipating pharmacies. If you

purchase covered drugs from

nonparticipating mail order pharmacies,

you will usually pay more.

When you purchase covered drugs from

nonparticipating pharmacies you are

responsible for the amount charged for the

drug at the time you fill your prescription,

and then you must file a claim to be

reimbursed. Once you submit a claim, you

will be reimbursed up to the maximum

allowable fee of the drug, less your payment

obligation. The maximum allowable fee may

be less than the amount you paid. In other

words, you are responsible for any

difference in cost between what the

pharmacy charges you for the drug and our

reimbursement amount.

See Participating vs. Nonparticipating

Pharmacies, page 65.

Form Number: Wellmark IA Grp/NR_ 0121 53 WEB T94

6. Notification Requirements and Care Coordination

Medical

Many services including, but not limited to, medical, surgical, mental health, and chemical

dependency treatment services, require a notification to us or a review by us. If you do not

follow notification requirements properly, you may have to pay for services yourself, so the

information in this section is critical. For a complete list of services subject to notification or

review, visit Wellmark.com or call the Customer Service number on your ID card.

Providers and Notification Requirements Providers in the Wellmark Blue HMO network should handle notification requirements for you.

If you are admitted to a Participating facility outside the Wellmark Blue HMO network, the

Participating Provider should handle notification requirements for you.

If you receive any other covered services (i.e., services unrelated to an inpatient admission) from

a Participating Provider outside the Wellmark Blue HMO network, or if you see an Out-of-

Network Provider, you or someone acting on your behalf is responsible for notification

requirements.

More than one of the notification requirements and care coordination programs described in

this section may apply to a service. Any notification or care coordination decision is based on the

medical benefits in effect at the time of your request. If your coverage changes for any reason,

you may be required to repeat the notification process.

You or your authorized representative, if you have designated one, may appeal a denial of

benefits resulting from these notification requirements and care coordination programs. See

Appeals, page 87. Also see Authorized Representative, page 95.

Precertification

Purpose Precertification helps determine whether a service or admission to a facility is

medically necessary. Precertification is required; however, it does not apply to

maternity or emergency services.

Applies to For a complete list of the services subject to precertification, visit

Wellmark.com or call the Customer Service number on your ID card.

Notification Requirements and Care Coordination

WEB T94 54 Form Number: Wellmark IA Grp/NR_ 0121

Person Responsible for Obtaining Precertification

You or someone acting on your behalf is responsible for obtaining

precertification if:

◼ You receive services subject to precertification from an Out-of-Network

Provider; or

◼ You receive non-inpatient services subject to precertification from a

Participating Provider outside the Wellmark Blue HMO network.

Please note: Services from Out-of-Network Providers or from

Participating Providers must be approved through the Referral process

described on page 45, except in the case of an emergency. Services from a

Participating Provider may be covered if you are in the guest membership

program.

Your Provider should obtain precertification for you if:

◼ You receive services subject to precertification from a Network Provider in

Iowa; or

◼ You receive inpatient services subject to precertification from a


Please note: If you are ever in doubt whether precertification has been

obtained, call the Customer Service number on your ID card.

Process When you, instead of your provider, are responsible for precertification, call

the phone number on your ID card before receiving services.

Wellmark will respond to a precertification request within:

◼ 72 hours in a medically urgent situation;

◼ 15 days in a non-medically urgent situation.

Precertification requests must include supporting clinical information to

determine medical necessity of the service or admission.

After you receive the service(s), Wellmark may review the related medical

records to confirm the records document the services subject to the approved

precertification request. The medical records also must support the level of

service billed and document that the services have been provided by the

appropriate personnel with the appropriate level of supervision.

Notification

Purpose Notification of most facility admissions and certain services helps us identify

and initiate discharge planning or care coordination. Notification is required.

Applies to For a complete list of the services subject to notification, visit Wellmark.com

or call the Customer Service number on your ID card.

Person Responsible

Network Providers perform notification for you. However, you or someone

acting on your behalf is responsible for notification if:

◼ You receive services subject to notification from a provider outside the




Process When you, instead of your provider, are responsible for notification, call the

phone number on your ID card before receiving services, except when you are

unable to do so due to a medical emergency. In the case of an emergency

admission, you must notify us within one business day of the admission or the

receipt of services or as soon as reasonably possible thereafter.

Prior Approval

Purpose Prior approval helps determine whether a proposed treatment plan is

medically necessary and a benefit under your medical benefits. Prior approval

is required.

Applies to For a complete list of the services subject to prior approval, visit


Person Responsible for Obtaining Prior Approval

You or someone acting on your behalf is responsible for obtaining prior

approval if:

◼ You receive services subject to prior approval from an Out-of-Network

Provider; or

◼ You receive non-inpatient services subject to prior approval from a


Please note: Services from Out-of-Network Providers or from

Participating Providers must be approved through the Referral process

described on page 45, except in the case of an emergency. Services from a

Participating Provider may be covered if you are in the guest membership

program.

Your Provider should obtain prior approval for you if:

◼ You receive services subject to prior approval from a Network Provider in

Iowa; or

◼ You receive inpatient services subject to prior approval from a


Please note: If you are ever in doubt whether prior approval has been

obtained, call the Customer Service number on your ID card.

Process When you, instead of your provider, are responsible for requesting prior

approval, call the number on your ID card to obtain a prior approval form and

ask the provider to help you complete the form.

Wellmark will determine whether the requested service is medically necessary

and eligible for benefits based on the written information submitted to us. We

will respond to a prior approval request in writing to you and your provider

within:

◼ 72 hours in a medically urgent situation.


Prior approval requests must include supporting clinical information to

determine medical necessity of the services or supplies.



Importance If your request is approved, the service is covered provided other contractual

requirements, such as member eligibility and benefits maximums, are

observed. If your request is denied, the service is not covered, and you will

receive a notice with the reasons for denial.

If you do not request prior approval for a service, the benefit for that service

will be denied on the basis that you did not request prior approval.

Upon receiving an Explanation of Benefits (EOB) indicating a denial of

benefits for failure to request prior approval, you will have the opportunity to

appeal (see the Appeals section) and provide us with medical information for

our consideration in determining whether the services were medically

necessary and a benefit under your medical benefits. Upon review, if we

determine the service was medically necessary and a benefit under your

medical benefits, the benefit for that service will be provided according to the

terms of your medical benefits.

Approved services are eligible for benefits for a limited time. Approval is

based on the medical benefits in effect and the information we had as of the

approval date. If your coverage changes for any reason (for example, because

of a new job or new medical benefits), an approval may not be valid. If your

coverage changes before the approved service is performed, a new approval is

recommended.

Concurrent Review

Purpose Concurrent review is a utilization review conducted during a member’s facility

stay or course of treatment at home or in a facility setting to determine

whether the place or level of service is medically necessary. This care

coordination program occurs without any notification required from you.

Applies to For a complete list of the services subject to concurrent review, visit


Person Responsible

Wellmark

Process Wellmark may review your case to determine whether your current level of

care is medically necessary.

Responses to Wellmark's concurrent review requests must include supporting

clinical information to determine medical necessity as a condition of your

coverage.

Importance Wellmark may require a change in the level or place of service in order to

continue providing benefits. If we determine that your current facility setting

or level of care is no longer medically necessary, we will notify you, your

attending physician, and the facility or agency at least 24 hours before your

benefits for these services end.

Case Management

Purpose Case management is intended to identify and assist members with the most

severe illnesses or injuries by collaborating with members, members’ families,

and providers to develop individualized care plans.



Applies to A wide group of members including those who have experienced potentially

preventable emergency room visits; hospital admissions/readmissions; those

with catastrophic or high cost health care needs; those with potential long

term illnesses; and those newly diagnosed with health conditions requiring

lifetime management. Examples where case management might be

appropriate include but are not limited to:

Brain or Spinal Cord Injuries

Cystic Fibrosis

Degenerative Muscle Disorders

Hemophilia

Pregnancy (high risk)

Transplants

Person Responsible

You, your physician, and the health care facility can work with Wellmark’s

case managers. Wellmark may initiate a request for case management.

Process Members are identified and referred to the Case Management program

through Customer Service and claims information, referrals from providers or

family members, and self-referrals from members.

Importance Case management is intended to identify and coordinate appropriate care and

care alternatives including reviewing medical necessity; negotiating care and

services; identifying barriers to care including contract limitations and

evaluation of solutions outside the group health plan; assisting the member

and family to identify appropriate community-based resources or government

programs; and assisting members in the transition of care when there is a

change in coverage.

Prescription Drugs

Prior Authorization of Drugs

Purpose Prior authorization allows us to verify that a prescription drug is part of a

specific treatment plan and is medically necessary.

Applies to Consult the Drug List to determine if a particular drug requires prior

authorization (including Retin-A (tretinion) for persons over age 30). You can

locate this list by visiting Wellmark.com. You may also check with your

pharmacist or practitioner to determine whether prior authorization applies

to a drug that has been prescribed for you.

Person Responsible

You are responsible for prior authorization.



Process Ask your practitioner to call us with the necessary information. If your

practitioner has not provided the prior authorization information,

participating pharmacists usually ask for it, which may delay filling your

prescription. To avoid delays, encourage your provider to complete the prior

authorization process before filling your prescription. Nonparticipating

pharmacists will fill a prescription without prior authorization but you will be

responsible for paying the charge.

Wellmark will respond to a prior authorization request within:

◼ 72 hours in a medically urgent situation.


Calls received after 4:00 p.m. are considered the next business day.

Importance If you purchase a drug that requires prior authorization but do not obtain

prior authorization, you are responsible for paying the entire amount charged.

Form Number: Wellmark IA Grp/YP_ 0121 59 WEB T94

7. Factors Affecting What You Pay

How much you pay for covered services is affected by many different factors discussed in this

section.

Medical

Benefit Year A benefit year is a period of 12 consecutive

months beginning on January 1 or

beginning on the day your coverage goes

into effect. The benefit year starts over each

January 1. Your benefit year continues even

if the University of Iowa changes Wellmark

group health plan benefits during the year

or you change to a different plan offering

mid-benefit year from the University of

Iowa.

Certain coverage changes result in your

Wellmark identification number changing.

In some cases, a new benefit year will start

under the new ID number for the rest of the

benefit year. In this case, the benefit year

would be less than a full 12 months. In other

cases (e.g., adding your spouse to your

coverage) the benefit year would continue

and not start over.

If you are an inpatient in a covered facility

on the date of your annual benefit year

renewal, your benefit limitations and

payment obligations, including your

deductible and out-of-pocket maximum, for

facility services will renew and will be based

on the benefit limitations and payment

obligation amounts in effect on the date you

were admitted. However, your payment

obligations, including your deductible and

out-of-pocket maximum, for practitioner

services will be based on the payment

obligation amounts in effect on the day you

receive services.

The benefit year is important for

calculating:

◼ Deductible.

◼ Coinsurance.

◼ Out-of-pocket maximum.

◼ Benefits maximum.

How Coinsurance is Calculated The amount on which coinsurance is

calculated depends on the state where you

receive a covered service and the

contracting status of the provider.

Wellmark Blue HMO and Out-of-Network Providers You are eligible for benefits from Out-of-

Network Providers only in cases of an

emergency, accidental injury, or in certain

situations, an approved referral.

Excluding hearing aid services and services

received at Out-of-Network facilities,

coinsurance is calculated using the payment

arrangement amount after the following

amounts (if applicable) are subtracted from

it:

◼ Deductible.

◼ Certain copayments.





Hearing Aid Services and Out-of-Network Facility Services For covered hearing aid services and

services received at out-of-network

facilities, coinsurance is calculated using the

amount charged after the following

applicable amounts are subtracted from it:

◼ Deductible.


Amounts representing any general




Factors Affecting What You Pay

WEB T94 60 Form Number: Wellmark IA Grp/YP_ 0121

Participating Providers Outside the Wellmark Blue HMO Network You are eligible for benefits from

Participating Providers only in cases of an

emergency, accidental injury, guest

membership, or in certain situations, an

approved referral.

The coinsurance for covered services is

calculated on the lower of:

◼ The amount charged for the covered

service, or

◼ The negotiated price that the Host Blue

makes available to Wellmark after the

following amounts (if applicable) are

subtracted from it:

⎯ Deductible.

⎯ Certain copayments.

⎯ Amounts representing any general

exclusions and conditions. See

General Conditions of Coverage,

Exclusions, and Limitations, page

39.

Often, the negotiated price will be a simple

discount that reflects an actual price the

local Host Blue paid to your provider.

Sometimes, the negotiated price is an

estimated price that takes into account

special arrangements with your healthcare

provider or provider group that may include

types of settlements, incentive payments,

and/or other credits or charges.

Occasionally, the negotiated price may be an

average price based on a discount that

results in expected average savings for

similar types of healthcare providers after

taking into account the same types of

transactions as with an estimated price.

Estimated pricing and average pricing,

going forward, also take into account

adjustments to correct for over- or under-

estimation of modifications of past pricing

for the types of transaction modifications

noted previously. However, such

adjustments will not affect the price we use

for your claim because they will not be

applied retroactively to claims already paid.

Occasionally, claims for services you receive

from a provider that participates with a Blue

Cross and/or Blue Shield Plan outside of

Iowa or South Dakota may need to be

processed by Wellmark instead of by the

BlueCard Program. In that case,

coinsurance is calculated using the payment

arrangement amount for covered services

after the following amounts (if applicable)

are subtracted from it:

◼ Deductible.






Laws in a small number of states may

require the Host Blue Plan to add a

surcharge to your calculation. If any state

laws mandate other liability calculation

methods, including a surcharge, Wellmark

will calculate your payment obligation for

any covered services according to applicable

law. For more information, see BlueCard

Program, page 46.

Provider Network Under the medical benefits of this plan,

your network of providers consists of

domestic providers and Wellmark Blue

HMO Providers. All other providers are not

in your network.

Participating Providers Participating Providers participate with a

Blue Cross and/or Blue Shield Plan, but not

with the Wellmark Blue HMO network.

When you receive services from

Participating Providers:

◼ You are eligible for benefits only in

limited situations. These are described

in the Choosing a Provider section.

◼ Wellmark makes claim payments

directly to these providers.

Network Providers Wellmark has a contracting relationship

with these providers. When you receive

services from a Network Provider:



◼ The Network payment obligation

amounts may be waived for certain

covered services. See Waived Payment

Obligations, page 9.

Out-of-Network Providers Wellmark and Blue Cross and/or Blue

Shield Plans do not have contracting

relationships with Out-of-Network

Providers, and they may not accept our

payment arrangements. Pharmacies other

than those participating in the specialty

pharmacy program that do not contract with

our pharmacy benefits manager are

considered Out-of-Network Providers.

Therefore, when you receive services from

Out-of-Network Providers:

◼ You are not eligible for benefits. There

may be exceptions to this rule for

specific services. If so, these are

described in the section Details –

Services Covered and Not Covered.

◼ You are responsible for any difference

between the amount charged and the

maximum allowable fee for a covered

service when the maximum allowable

fee is less than the practitioner’s charge.

In the case of services received outside

Iowa or South Dakota, our maximum

payment for services by an Out-of-

Network Provider may be the lesser of

Wellmark’s maximum allowable fee or

the amount allowed by the Blue Cross or

Blue Shield Plan in the state where the

provider is located. See Services Outside

the Wellmark Blue HMO Network, page

46.

◼ Wellmark does not make claim

payments directly to these providers.

You are responsible for ensuring that

your provider is paid in full.

◼ The group health plan payment for Out-

of-Network hospitals, M.D.s, and D.O.s

in Iowa is made payable to the provider,

but the check is sent to you. You are

responsible for forwarding the check to

the provider (plus any billed balance you

may owe).

Amount Charged and Maximum Allowable Fee

Amount Charged The amount charged is the amount a

provider charges for a service or supply,

regardless of whether the services or

supplies are covered under your medical

benefits.

Maximum Allowable Fee The maximum allowable fee is the amount,

established by Wellmark, using various

methodologies, for covered services and

supplies. Wellmark’s amount paid may be

based on the lesser of the amount charged

for a covered service or supply or the

maximum allowable fee.

Payment Arrangements

Payment Arrangement Savings Wellmark has contracting relationships with

Network Providers. We use different

methods to determine payment

arrangements, including negotiated fees.

These payment arrangements usually result

in savings.

The savings from payment arrangements

and other important amounts will appear on

your Explanation of Benefits statement as

follows:

◼ Network Savings, which reflects the

amount you save on a claim by receiving

services from a Participating or Network

provider. For the majority of services,

the savings reflects the actual amount

you save on a claim. However,

depending on many factors, the amount

we pay a provider could be different

from the covered charge. Regardless of

the amount we pay a Participating or

Network provider, your payment

responsibility will always be based on

the lesser of the covered charge or the

maximum allowable fee.

◼ Amount Not Covered, which reflects the

portion of provider charges not covered

under your health benefits and for which

you are responsible. This amount may



include services or supplies not covered;

amounts in excess of a benefit

maximum, benefit year maximum, or

lifetime benefits maximum; denials for

failure to follow a required

precertification; and the difference

between the amount charged and the

maximum allowable fee for services

from an Out-of-Network Provider. For

general exclusions and examples of

benefit limitations, see General



◼ Amount Paid by Health Plan, which

reflects our payment responsibility to a

provider or to you. We determine this

amount by subtracting the following

amounts (if applicable) from the amount

charged:

⎯ Deductible.

⎯ Coinsurance.

⎯ Copayment.

⎯ Amounts representing any general

exclusions and conditions.

⎯ Network savings.

Payment Method for Services When you receive a covered service or

services that result in multiple claims, we

will calculate your payment obligations

based on the order in which we process the

claims.

Provider Payment Arrangements Provider payment arrangements are

calculated using industry methods

including, but not limited to, fee schedules,

per diems, percentage of charge, capitation,

or episodes of care. Some provider payment

arrangements may include an amount

payable to the provider based on the

provider’s performance. Performance-based

amounts that are not distributed are not

allocated to your specific group or to your

specific claims and are not considered when

determining any amounts you may owe. We

reserve the right to change the methodology

we use to calculate payment arrangements

based on industry practice or business need.

Wellmark Blue HMO and Participating

providers agree to accept our payment

arrangements as full settlement for

providing covered services, except to the

extent of any amounts you may owe.

Capitation Payment to healthcare providers for certain

services is made according to a uniform

amount per patient as determined by

Wellmark Health Plan of Iowa, Inc.

Pharmacy Benefits Manager Fees and Drug Company Rebates Wellmark contracts with a pharmacy

benefits manager to provide pharmacy

benefits management services to its

accounts, such as your group. Your group is

to pay a monthly fee for such services.

Drug manufacturers offer rebates to

pharmacy benefits managers. After your

group has had Wellmark prescription drug

coverage for at least nine months, the

pharmacy benefits manager contracting

with Wellmark will calculate, on a quarterly

basis, your group’s use of drugs for which

rebates have been paid. Wellmark receives

these rebates. Your group will be credited

with rebate amounts forwarded to us by the

pharmacy benefits manager unless your

group’s arrangement with us requires us to

reduce such rebated amounts by the amount

of any fees we paid to the pharmacy benefits

manager for the services rendered to your

group. We will not distribute these rebate

amounts to you, and rebates will not be

considered when determining your payment

obligations.



Prescription Drugs

Benefit Year A benefit year is a period of 12 consecutive

months beginning on January 1 or

beginning on the day your coverage goes

into effect. The benefit year starts over each

January 1. Your benefit year continues even

if the University of Iowa changes Wellmark

group health plan benefits during the year

or you change to a different plan offering

mid-benefit year from the University of

Iowa.

Certain coverage changes result in your

Wellmark identification number changing.

In some cases, a new benefit year will start

under the new ID number for the rest of the

benefit year. In this case, the benefit year

would be less than a full 12 months. In other

cases (e.g., adding your spouse to your

coverage) the benefit year would continue

and not start over.

The benefit year is important for

calculating:

◼ Out-of-pocket maximum.

Wellmark Blue Rx Value Plus Drug List Often there is more than one medication

available to treat the same medical

condition. The Wellmark Blue Rx Value Plus

Drug List (“Drug List”) contains drugs and


devices physicians recognize as medically

effective for a wide range of health

conditions.

The Drug List is maintained with the

assistance of practicing physicians,

pharmacists, and Wellmark’s pharmacy

department.

To determine if a drug or pharmacy durable

medical equipment device is covered, you or

your physician must consult the Drug List.

If a drug or pharmacy durable medical

equipment device is not on the Drug List, it

is not covered.

If you need help determining if a particular

drug or pharmacy durable medical

equipment device is on the Drug List, ask

your physician or pharmacist, visit our

website, Wellmark.com, or call the


Although only drugs and pharmacy durable

medical equipment devices listed on the

Drug List are covered, physicians are not

limited to prescribing only the drugs on the

list. Physicians may prescribe any

medication, but only medications on the

Drug List are covered. Please note: A

medication or pharmacy durable medical

equipment device on the Drug List will not

be covered if the drug or pharmacy durable

medical equipment device is specifically

excluded under your Blue Rx Value Plus

prescription drug benefits, or other

limitations apply.

If a drug or pharmacy durable medical

equipment device is not on the Wellmark

Blue Rx Value Plus Drug List and you

believe it should be covered, refer to

Exception Requests for Non-Formulary


The Wellmark Blue Rx Value Plus Drug List

is subject to change.

Tiers The Wellmark Blue Rx Value Plus Drug List

also identifies which tier a drug is on:

Tier 1. Generic drugs and some brand-

name drugs that have no medically

appropriate generic equivalent. Tier 1 drugs

have the lowest payment obligation.

Tier 2. Drugs appear on this tier because

they either have no medically appropriate

generic equivalent or are considered less

cost-effective than Tier 1 drugs. Tier 2 drugs

have a higher payment obligation than Tier

1 drugs.

Tier 3. Drugs appear on this tier because

they are less cost-effective than Tier 1 or



Tier 2 drugs. Tier 3 drugs have the highest

payment obligation.

Pharmacy DME. Devices available on this

tier include select durable medical

equipment (DME) that are used in

conjunction with a drug and may be

obtained from a pharmacy.

Generic and Brand Name Drugs

Generic Drug Generic drug refers to an FDA-approved

“A”-rated generic drug. This is a drug with

active therapeutic ingredients chemically

identical to its brand name drug

counterpart.

Brand Name Drug Brand name drug is a prescription drug

patented by the original manufacturer.

Usually, after the patent expires, other

manufacturers may make FDA-approved

generic copies.

Sometimes, a patent holder of a brand name

drug grants a license to another

manufacturer to produce the drug under a

generic name, though it remains subject to

patent protection and has a nearly identical

price. In these cases, Wellmark’s pharmacy

benefits manager may treat the licensed

product as a brand name drug, rather than

generic, and will calculate your payment

obligation accordingly.

What You Pay In most cases, when you purchase a brand

name drug that has an FDA-approved “A”-

rated medically appropriate generic

equivalent, Wellmark will pay only what it

would have paid for the medically

appropriate equivalent generic drug. You

will be responsible for your payment

obligation for the medically appropriate

equivalent generic drug and any remaining

cost difference up to the maximum allowed

fee for the brand name drug.

However, if your physician writes “dispense

as written” on your prescription

◼ You will not be responsible for the cost

difference between the generic drug and

the brand name drug;

◼ You will be responsible for your

payment obligation for the brand name

drug.

Quantity Limitations Most prescription drugs are limited to a

maximum quantity you may receive in a

single prescription.

Federal regulations limit the quantity that

may be dispensed for certain medications. If

your prescription is so regulated, it may not

be available in the amount prescribed by

your physician.

In addition, coverage for certain drugs or


devices is limited to specific quantities per

month, benefit year, or lifetime. Amounts in

excess of quantity limitations are not

covered.

For a list of drugs and pharmacy durable

medical equipment devices with quantity

limits, check with your pharmacist or

physician or consult the Wellmark Blue Rx

Value Plus Drug List at Wellmark.com, or


ID card.

Amount Charged and Maximum Allowable Fee

Amount Charged The retail price charged by a pharmacy for a

covered prescription drug or pharmacy

durable medical equipment device.

Maximum Allowable Fee The amount, established by Wellmark using

various methodologies and data (such as the

average wholesale price), payable for

covered drugs and pharmacy durable

medical equipment devices.

The maximum allowable fee may be less

than the amount charged for the drug or


device.



Participating vs. Nonparticipating Pharmacies If you purchase a covered prescription drug

at a nonparticipating pharmacy, you are

responsible for the amount charged for the

drug at the time you fill your prescription,

and then you must file a claim.

Once you submit a claim, you will be

reimbursed up to the maximum allowable

fee of the drug, less your coinsurance. The

maximum allowable fee may be less than

the amount you paid. In other words, you

are responsible for any difference in cost

between what the pharmacy charges you for

the drug and our reimbursement amount.

Your payment obligation for the purchase of

a covered prescription drug at a

participating pharmacy is the lesser of your

coinsurance, the maximum allowable fee, or

the amount charged for the drug.

To determine if a pharmacy is participating,

ask the pharmacist, consult the directory of

participating pharmacies on our website at


number on your ID card. Our directory also

is available upon request by calling the


Special Programs We evaluate and monitor changes in the

pharmaceutical industry in order to

determine clinically effective and cost-

effective coverage options. These

evaluations may prompt us to offer

programs that encourage the use of

reasonable alternatives. For example, we

may, at our discretion, temporarily waive

your payment obligation on a qualifying

prescription drug purchase.

Visit our website at Wellmark.com or call us

to determine whether your prescription

qualifies.

Savings and Rebates

Payment Arrangements The benefits manager of this prescription

drug program has established payment

arrangements with participating pharmacies

that may result in savings.

Pharmacy Benefits Manager Fees and Drug Company Rebates Wellmark contracts with a pharmacy

benefits manager to provide pharmacy

benefits management services to its

accounts, such as your group. Your group is

to pay a monthly fee for such services.

Drug manufacturers offer rebates to

pharmacy benefits managers. After your

group has had Wellmark prescription drug

coverage for at least nine months, the

pharmacy benefits manager contracting

with Wellmark will calculate, on a quarterly

basis, your group’s use of drugs for which

rebates have been paid. Wellmark receives

these rebates. Your group will be credited

with rebate amounts forwarded to us by the

pharmacy benefits manager unless your

group’s arrangement with us requires us to

reduce such rebated amounts by the amount

of any fees we paid to the pharmacy benefits

manager for the services rendered to your

group. We will not distribute these rebate

amounts to you, and rebates will not be

considered when determining your payment

obligations.

Form Number: Wellmark IA Grp/ELG_ 0121 67 WEB T94

8. Coverage Eligibility and Effective Date

Eligible Members You are eligible for coverage if you meet the

University of Iowa’s eligibility requirements.

Your spouse or domestic partner may also

be eligible for coverage if spouses or

domestic partners are covered under this

plan.

If a child is eligible for coverage under the

University of Iowa’s eligibility requirements,

the child must have one of the following

relationships to the plan member or an

enrolled spouse or domestic partner:

◼ A biological child.

◼ Legally adopted or placed for adoption

(that is, you assume a legal obligation to

provide full or partial support and

intend to adopt the child).

◼ A child for whom you have legal

guardianship.

◼ A stepchild.

◼ A foster child.

◼ A biological child a court orders to be

covered.

A child who has been placed in your home

for the purpose of adoption or whom you

have adopted is eligible for coverage on the

date of placement for adoption or the date

of actual adoption, whichever occurs first.

Please note: You must notify us or the

University of Iowa if you enter into an

arrangement to provide surrogate parent

services: Contact the University of Iowa or


ID card.

In addition, a child must be one of the

following:

◼ A child up to age 26.

◼ A full-time student enrolled in an

accredited educational institution. Full-

time student status continues during:

⎯ Regularly-scheduled school

vacations; and

⎯ Medically necessary leaves of

absence until the earlier of one year

from the first day of leave or the date

coverage would otherwise end.

◼ An unmarried child who is deemed

disabled. The disability must have

existed before the child turned age 26 or

while the child was a full-time student.

Wellmark considers a dependent

disabled when he or she meets the

following criteria:

⎯ Claimed as a dependent on the

employee’s, plan member’s,

subscriber’s, policyholder’s, or

retiree’s tax return; and

⎯ Enrolled in and receiving Medicare

benefits due to disability; or

⎯ Enrolled in and receiving Social

Security benefits due to disability.

Documentation will be required.

Please note: In addition to the preceding

requirements, eligibility is affected by

coverage enrollment events and coverage

termination events. See Coverage Change

Events, page 71.

When Coverage Begins Coverage begins on the member’s effective

date. If you have just started a new job, or if

a coverage enrollment event allows you to

add a new member, ask the University of

Iowa about your effective date. Services

received before the effective date of

coverage are not eligible for benefits.

Late Enrollees A late enrollee is a member who declines

coverage when initially eligible to enroll and

then later wishes to enroll for coverage.

However, a member is not a late enrollee if a

qualifying enrollment event allows

enrollment as a special enrollee, even if the

enrollment event coincides with a late

enrollment opportunity. See Coverage

Change Events, page 71.

Coverage Eligibility and Effective Date

WEB T94 68 Form Number: Wellmark IA Grp/ELG_ 0121

A late enrollee may enroll for coverage at

the group’s next renewal or enrollment

period.

Changes to Information Related to You or to Your Benefits Wellmark may, from time to time, permit

changes to information relating to you or to

your benefits. In such situations, Wellmark

shall not be required to reprocess claims as

a result of any such changes.

Qualified Medical Child Support Order If you have a dependent child and the

University of Iowa receives a Medical Child

Support Order recognizing the child’s right

to enroll in this group health plan or in your

spouse’s benefits plan, the University of

Iowa will promptly notify you or your

spouse and the dependent that the order has

been received. The University of Iowa also

will inform you or your spouse and the

dependent of its procedures for determining

whether the order is a Qualified Medical

Child Support Order (QMCSO). Participants

and beneficiaries can obtain, without

charge, a copy of such procedures from the

plan administrator.

A QMCSO specifies information such as:

◼ Your name and last known mailing

address.

◼ The name and mailing address of the

dependent specified in the court order.

◼ A reasonable description of the type of

coverage to be provided to the

dependent or the manner in which the

type of coverage will be determined.

◼ The period to which the order applies.

A Qualified Medical Child Support Order

cannot require that a benefits plan provide

any type or form of benefit or option not

otherwise provided under the plan, except

as necessary to meet requirements of Iowa

Code Chapter 252E (2001) or Social

Security Act Section 1908 with respect to

group health plans.

The order and the notice given by the

University of Iowa will provide additional

information, including actions that you and

the appropriate insurer must take to

determine the dependent’s eligibility and

procedures for enrollment in the benefits

plan, which must be done within specified

time limits.

If eligible, the dependent will have the same

coverage as you or your spouse and will be

allowed to enroll immediately. The

University of Iowa will withhold any

applicable share of the cost of the

dependent’s health care coverage from your

compensation and forward this amount to

us.

If you are subject to a waiting period that

expires more than 90 days after we receive

the QMCSO, the University of Iowa must

notify us when you become eligible for

enrollment. Enrollment of the dependent

will commence after you have satisfied the

waiting period.

The dependent may designate another

person, such as a custodial parent or legal

guardian, to receive copies of explanations

of benefits, checks, and other materials.

The University of Iowa may not revoke

enrollment or eliminate coverage for a

dependent unless the University of Iowa

receives satisfactory written evidence that:

◼ The court or administrative order

requiring coverage in a group health

plan is no longer in effect;

◼ The dependent’s eligibility for or

enrollment in a comparable benefits

plan that takes effect on or before the

date the dependent’s enrollment in this

group health plan terminates; or

◼ The employer eliminates dependent

health coverage for all employees.

The University of Iowa is not required to

maintain the dependent’s coverage if:

◼ You or your spouse no longer pay the

cost of coverage because the University

of Iowa no longer owes compensation;

or

Coverage Eligibility and Effective Date

Form Number: Wellmark IA Grp/ELG_ 0121 69 WEB T94

◼ You or your spouse have terminated

employment with the University of Iowa

and have not elected to continue

coverage.

Form Number: Wellmark IA Grp/CC_ 0121 71 WEB T94

9. Coverage Changes and Termination

Certain events may require or allow you to

add or remove persons who are covered by

this group health plan.

Coverage Change Events Coverage Enrollment Events: The

following events allow you or your eligible

child to enroll for coverage. The following

events may also allow your spouse or

domestic partner to enroll for coverage if

spouses or domestic partners are eligible for

coverage under this plan. If the University

of Iowa offers more than one group health

plan, the event also allows you to move from

one plan option to another.

◼ Birth, adoption, or placement for

adoption by an approved agency.

◼ Marriage.

◼ Exhaustion of COBRA coverage.

◼ You or your eligible spouse or your

dependent loses eligibility for creditable

coverage or his or her employer or the

University of Iowa ceases contribution

to creditable coverage.

◼ Spouse (if eligible for coverage) loses

coverage through his or her employer.

◼ You lose eligibility for coverage under

Medicaid or the Children’s Health

Insurance Program (CHIP) (the hawk-i

plan in Iowa).

◼ You become eligible for premium

assistance under Medicaid or CHIP.

The following events allow you to add only

the new dependent resulting from the event:

◼ Dependent child resumes status as a

full-time student.

◼ Addition of a biological child by court

order. See Qualified Medical Child

Support Order, page 68.

◼ Appointment as a child’s legal guardian.

◼ Placement of a foster child in your home

by an approved agency.

Coverage Removal Events: The

following events require you to remove the

affected family member from your coverage:

◼ Death.

◼ Divorce or annulment (if spouses are

eligible for coverage under this plan).

Legal separation, also, may result in

removal from coverage. If you become

legally separated, notify the University

of Iowa.

◼ Medicare eligibility. If you become

eligible for Medicare, you must notify

the University of Iowa immediately. If

you are eligible for this group health

plan other than as a current employee or

a current employee’s spouse (if spouses

are eligible for coverage under this

plan), your Medicare eligibility may

terminate this coverage.

In case of the following coverage removal

events, the affected child’s coverage may be

continued until the end of the month on or

after the date of the event:

◼ Completion of full-time schooling if the

child is age 26 or older.

In the case of children that are not full-time

students or permanently disabled, coverage

may be continued until the end of the year

the child turns age 26.

Reinstatement of Child Reinstatement Events. A child up to age

26 who was removed from coverage may be

reinstated on his or her parent’s existing

coverage under any of the following

conditions:

◼ Involuntary loss of creditable coverage

(including, but not limited to, group or

hawk-i coverage).

◼ Loss of creditable coverage due to:

⎯ Termination of employment or

eligibility.

⎯ Death of spouse.

⎯ Divorce.

Coverage Changes and Termination

WEB T94 72 Form Number: Wellmark IA Grp/CC_ 0121

◼ Court ordered coverage for spouse or

minor children under the parent’s health

insurance.

◼ Exhaustion of COBRA or Iowa

continuation coverage.

◼ The plan member is employed by an

employer that offers multiple health

plans and elects a different plan during

an open enrollment period.

◼ A change in status in which the

employee becomes eligible to enroll in

this group health plan and requests

enrollment. See Coverage Enrollment

Events earlier in this section.

Reinstatement Requirements. A

request for reinstated coverage for a child

up to age 26 must be made within 31 days of

the reinstatement event. In addition, the

following requirements must be met:

◼ The child must have been covered under

the parent’s current coverage at the time

the child left that coverage to enroll in

other creditable coverage.

◼ The parent’s coverage must be currently

in effect and continuously in effect

during the time the child was enrolled in

other creditable coverage.

Requirement to Notify Group Sponsor You must notify the University of Iowa

Benefits Office of an event that changes the

coverage status of members. Notify the

University of Iowa Benefits Office within 60

days in case of the following events:

◼ A birth, adoption, or placement for

adoption.

For all other events, you must notify the

University of Iowa Benefits Office within 30

days of the event.

If you do not provide timely notification of

an event that requires you to remove an

affected family member, your coverage may

be terminated.

If you do not provide timely notification of a

coverage enrollment event, the affected

person may not enroll until an annual group

enrollment period.

Coverage Termination The following events terminate your

coverage eligibility.

◼ You become unemployed when your

eligibility is based on employment.

◼ You become ineligible under the

University of Iowa’s eligibility

requirements for reasons other than

unemployment.

◼ The University of Iowa discontinues or

replaces this group health plan.

◼ We decide to discontinue offering this

group health benefit plan by giving

written notice to you and the University

of Iowa and the Commissioner of

Insurance at least 90 days prior to

termination.

◼ We decide to nonrenew all group health

benefit plans delivered or issued for

delivery to employers in Iowa by giving

written notice to you and the University

of Iowa and the Commissioner of

Insurance at least 180 days prior to

termination.

◼ The number of individuals covered

under this group health plan falls below

the number or percentage of eligible

individuals required to be covered.

◼ Your employer sends a written request

to terminate coverage.

Also see Fraud or Intentional

Misrepresentation of Material Facts, and

Nonpayment later in this section.

When you become unemployed and your

eligibility is based on employment, your

coverage will end at the end of the month

your employment ends. When your

coverage terminates for all other reasons,

check with the University of Iowa or call the

Customer Service number on your ID card

to verify the coverage termination date.

If you receive covered facility services as an

inpatient of a hospital or a resident of a

nursing facility on the date your coverage

eligibility terminates, payment for the



covered facility services will end on the

earliest of the following:

◼ The end of your remaining days of

coverage under this benefits plan.

◼ The date you are discharged from the

hospital or nursing facility following

termination of your coverage eligibility.

◼ A period not more than 60 days from

the date of termination.

Only facility services will be covered under

this extension of benefits provision. Benefits

for professional services will end on the date

of termination of your coverage eligibility.

Fraud or Intentional Misrepresentation of Material Facts Your coverage will terminate immediately if:

◼ You use this group health plan

fraudulently or intentionally

misrepresent a material fact in your

application; or

◼ The University of Iowa commits fraud or

intentionally misrepresents a material

fact under the terms of this group health

plan.

If your coverage is terminated for fraud or

intentional misrepresentation of a material

fact, then:

◼ We may declare this group health plan

void retroactively from the effective date

of coverage following a 30-day written

notice. In this case, we will recover any

claim payments made.

◼ Premiums may be retroactively adjusted

as if the fraud or intentionally

misrepresented material fact had been

accurately disclosed in your application.

◼ We will retain legal rights, including the

right to bring a civil action.

Nonpayment If you or the University of Iowa fail to make

required payments to us when due or within

the allowed grace period, your coverage will

terminate the last day of the month in which

the required payments are due.

Coverage Continuation When your coverage ends, you may be

eligible to continue coverage under this

group health plan.

COBRA Continuation The federal Consolidated Omnibus Budget

Reconciliation Act (COBRA) applies to most

non-governmental employers with 20 or

more employees. Generally, COBRA entitles

you and eligible dependents to continue

coverage if it is lost due to a qualifying

event, such as employment termination,

divorce, or loss of dependent status. You

and your eligible dependents will be

required to pay for continuation coverage.

Other federal or state laws similar to

COBRA may apply if COBRA does not. The

University of Iowa is required to provide

you with additional information on

continuation coverage if a qualifying event

occurs.

Continuation for Public Group Iowa Code Sections 509A.7 and 509A.13

may apply if you are an employee of the

State, an Iowa school district, or other

public entity supported by public funds. If

this law applies to you, you may be entitled

to continue participation in this medical

benefits plan when you retire.

Coverage Continuation or Reenrollment Upon Death of Eligible Peace Officer or Fire Fighter in the Line of Duty Pursuant to Iowa Code Section 509A.13C, a

governing body, county board of

supervisors, or city council that sponsors a

health care coverage plan for its employees

under Iowa Code chapter 509A shall permit

continuation of existing coverage or

reenrollment in previously existing health

coverage for the surviving spouse and each

surviving child of an eligible peace officer or

fire fighter. An “eligible peace officer or fire

fighter” means a peace officer, as defined in

Iowa Code Section 801.4, or a fire fighter, as

defined in Iowa Code Section 411.1, to which

a line of duty death benefit is payable

pursuant to Iowa Code Section 97A.6,


WEB T94 74 Form Number: Wellmark IA Grp/CC_ 0121

Subsection 16, Iowa Code Section 97B.52,

Subsection 2, or Iowa Code Section 411.6,

Subsection 15. A governing body, a county

board of supervisors, or a city council shall

also permit continuation of existing

coverage for the surviving spouse and each

surviving child of an eligible peace officer or

fire fighter until such time as the

determination is made as to whether to

provide a line of duty death benefit.

Iowa Code Section 509A.13C applies

retroactively to allow reenrollment in

previously existing health coverage for the

surviving spouse and each surviving child of

an eligible peace officer or fire fighter who

died in the line of duty on or after January 1,

1985. Coverage benefits will be provided for

services on or after the date of reenrollment.

Eligibility for continuation and

reenrollment are subject to any applicable

conditions and limitations in Iowa Code

Section 509A.13C. To request coverage

continuation or reenrollment under Iowa

Code Section 509A.13C, the surviving

spouse, on his/her behalf and on behalf of

each surviving child, must provide written

notification to the applicable governing

body, county board of supervisors, or city

council. The governing body, county board

of supervisors, or city council must then

notify Wellmark of the continuation or

reenrollment request.

The governing body, county board of

supervisors, or city council is not required to

pay for the cost of the coverage for the

surviving spouse and children but may

choose to pay the cost or a portion of the

cost for the coverage. If the full cost of the

coverage is not paid by the governing body,

county board of supervisors, or city council,

the surviving spouse, on his/her behalf and

on behalf of each surviving child, may elect

to continue the health care coverage by

paying that portion of the cost of the

coverage not paid by the governing body,

county board of supervisors, or city council.

The continuation and reenrollment options

are not available if the surviving spouse or

surviving child who would otherwise be

entitled to continuation or reenrollment

under this section was, through the

surviving spouse’s or surviving child’s

actions, a substantial contributing factor to

the death of the eligible peace officer or fire

fighter.

Continuation Under Iowa Law Under Iowa Code Chapter 509B, you may be

eligible to continue your medical care

coverage for up to nine months if:

◼ You lose the coverage you have been

receiving through the University of

Iowa; and

◼ You have been covered by your medical

benefits plan continuously for the last

three months.

The University of Iowa must provide written

notice of your right to continue coverage

within 10 days of the last day you are

considered employed or your coverage ends.

You will then have 10 days to give the

University of Iowa written notice that you

want to continue coverage.

Your right to continue coverage ends 31

days after the date of your employment

termination or the date you were given

notice of your continuation right, whichever

is later.

If you lose your coverage because of divorce,

annulment, or death of the employee, you

must notify the University of Iowa providing

the coverage within 31 days.

Benefits provided by continuation coverage

may not be identical to the benefits that

active employees have and will be subject to

different premium rates. You will be

responsible for paying any premiums to the

University of Iowa for continuation

coverage.

If you believe the Iowa continuation law

applies to you, you may contact the

University of Iowa for information on

premiums and any necessary paperwork.

If you are eligible for coverage continuation

under both Iowa law and COBRA, your



employer can comply with Iowa law by

offering only COBRA continuation.

Form Number: Wellmark IA Grp/CL_ 0121 77 WEB T94

10. Claims

Once you receive services, we must receive a

claim to determine the amount of your

benefits. The claim lets us know the services

you received, when you received them, and

from which provider.

Neither you nor your provider shall bill

Wellmark for services provided under a

direct primary care agreement as authorized

under Iowa law.

When to File a Claim You need to file a claim if you:

◼ Use a provider who does not file claims

for you. Network Providers file claims

for you.

◼ Purchase prescription drugs from a

nonparticipating pharmacy.

◼ Purchase prescription drugs from a

participating pharmacy but do not

present your ID card.

◼ Pay in full for a drug that you believe

should have been covered.

Your submission of a prescription to a

participating pharmacy is not a filed claim

and therefore is not subject to appeal

procedures as described in the Appeals

section. However, you may file a claim with

us for a prescription drug purchase you

think should have been a covered benefit.

Wellmark must receive claims within 180

days following the date of service of the

claim or if you have other coverage that has

primary responsibility for payment then

within 180 days of the date of the other

carrier's explanation of benefits. If you

receive services outside of Wellmark’s

service area, Wellmark must receive the

claim within 180 days following the date of

service or within the filing requirement in

the contractual agreement between the

Participating Provider and the Host Blue. If


Network Provider, the claim has to be filed

within 180 days following the date of

service.

How to File a Claim All claims must be submitted in writing.

1. Get a Claim Form Forms are available at Wellmark.com or by

calling the Customer Service number on

your ID card or from your personnel

department.

2. Fill Out the Claim Form Follow the same claim filing procedure

regardless of where you received services.

Directions are printed on the back of the

claim form. Complete all sections of the

claim form. For more efficient processing,

all claims (including those completed out-

of-country) should be written in English.

If you need assistance completing the claim

form, call the Customer Service number on

your ID card.

Medical Claim Form. Follow these steps

to complete a medical claim form:

◼ Use a separate claim form for each

covered family member and each

provider.

◼ Attach a copy of an itemized statement

prepared by your provider. We cannot

accept statements you prepare, cash

register receipts, receipt of payment

notices, or balance due notices. In order

for a claim request to qualify for

processing, the itemized statement must

be on the provider’s stationery, and

include at least the following:

⎯ Identification of provider: full name,

address, tax or license ID numbers,

and provider numbers.

⎯ Patient information: first and last

name, date of birth, gender,

relationship to plan member, and

daytime phone number.

⎯ Date(s) of service.

⎯ Charge for each service.

⎯ Place of service (office, hospital,

etc.).

Claims

WEB T94 78 Form Number: Wellmark IA Grp/CL_ 0121

⎯ For injury or illness: date and

diagnosis.

⎯ For inpatient claims: admission

date, patient status, attending

physician ID.

⎯ Days or units of service.

⎯ Revenue, diagnosis, and procedure

codes.

⎯ Description of each service.

Prescription Drugs Covered Under

Your Medical Benefits Claim Form.

For prescription drugs covered under your

medical benefits (not covered under your


benefits), use a separate prescription drug

claim form and include the following

information:

◼ Pharmacy name and address.

◼ Patient information: first and last name,

date of birth, gender, and relationship to

plan member.

◼ Date(s) of service.

◼ Description and quantity of drug.

◼ Original pharmacy receipt or cash

receipt with the pharmacist’s signature

on it.

Blue Rx Value Plus Prescription Drug

Claim Form. For prescription drugs

covered under your Blue Rx Value Plus

prescription drug benefits, complete the

following steps:

◼ Use a separate claim form for each

covered family member and each

pharmacy.

◼ Complete all sections of the claim form.

Include your daytime telephone

number.

◼ Submit up to three prescriptions for the

same family member and the same

pharmacy on a single claim form. Use

additional claim forms for claims that

exceed three prescriptions or if the

prescriptions are for more than one

family member or pharmacy.

◼ Attach receipts to the back of the claim

form in the space provided.

3. Sign the Claim Form

4. Submit the Claim We recommend you retain a copy for your

records. The original form you send or any

attachments sent with the form cannot be

returned to you.

Medical Claims and Claims for Drugs

Covered Under Your Medical

Benefits. Send the claim to:

Wellmark

Station 1E238

P.O. Box 9291

Des Moines, IA 50306-9291

Medical Claims for Services Received

Outside the United States. Send the

claim to the address printed on the claim

form.

Blue Rx Value Plus Prescription Drug

Claims. Send the claim to the address

printed on the claim form.

We may require additional information

from you or your provider before a claim

can be considered complete and ready for

processing.

Notification of Decision You will receive an Explanation of Benefits

(EOB) following your claim. The EOB is a

statement outlining how we applied benefits

to a submitted claim. It details amounts that

providers charged, network savings, our

paid amounts, and amounts for which you

are responsible.

In case of an adverse decision, the notice

will be sent within 30 days of receipt of the

claim. We may extend this time by up to 15

days if the claim determination is delayed

for reasons beyond our control. If we do not

send an explanation of benefits statement or

a notice of extension within the 30-day

period, you have the right to begin an

appeal. We will notify you of the

circumstances requiring an extension and

the date by which we expect to render a

decision.

Claims

Form Number: Wellmark IA Grp/CL_ 0121 79 WEB T94

If an extension is necessary because we

require additional information from you,

the notice will describe the specific

information needed. You have 45 days from

receipt of the notice to provide the

information. Without complete information,

your claim will be denied.

If you have other insurance coverage, our

processing of your claim may utilize

coordination of benefits guidelines. See

Coordination of Benefits, page 81.

Once we pay your claim, whether our

payment is sent to you or to your provider,

our obligation to pay benefits for the claim

is discharged. However, we may adjust a

claim due to overpayment or

underpayment. In the case of Out-of-

Network hospitals, M.D.s, and D.O.s located

in Iowa, the health plan payment is made

payable to the provider, but the check is

sent to you. You are responsible for

forwarding the check to the provider, plus

any difference between the amount charged

and our payment.

Exception Requests for Non-Formulary Prescription Drugs Prescription drugs that are not listed on the

Wellmark Blue Rx Value Plus Drug List are

not covered. However, you may submit an

exception request for coverage of a non-

formulary drug (i.e., a drug that is not

included on the Wellmark Blue Rx Value

Plus Drug List). The form is available at

Wellmark.com or by calling the Customer

Service number on your ID card. Your

prescribing physician or other provider

must provide a clinical justification

supporting the need for the non-formulary

drug to treat your condition. The provider

should include a statement that:

◼ All covered formulary drugs on any tier

have been ineffective; or


will be ineffective; or


would not be as effective as the non-

formulary drug; or

◼ All covered formulary drugs would have

adverse effects.

Wellmark will respond within 72 hours of

receiving the Exception Request for Non-

Formulary Prescription Drugs form. For

expedited requests, Wellmark will respond

within 24 hours.

In the event Wellmark denies your

exception request, you and your provider

will be sent additional information

regarding your ability to request an

independent review of our decision. If the

independent reviewer approves your

exception request, we will treat the drug as a

covered benefit for the duration of your

prescription. You will be responsible for

out-of-pocket costs (for example:

deductible, copay, or coinsurance, if

applicable) as if the non-formulary drug is

on the highest tier of the Wellmark Blue Rx

Value Plus Drug List. Amounts you pay will

be counted toward any applicable out-of-

pocket maximums. If the independent

reviewer upholds Wellmark’s denial of your

exception request, the drug will not be

covered, and this decision will not be

considered an adverse benefit

determination, and will not be eligible for

further appeals. You may choose to

purchase the drug at your own expense.

The Exception Request for Non-Formulary

Prescription Drugs process is only available

for FDA-approved prescription drugs that

are not on the Wellmark Blue Rx Value Plus

Drug List. It is not available for items that

are specifically excluded under your

benefits, such as cosmetic drugs,

convenience packaging, non-FDA approved

drugs, drugs not approved to be covered by

Wellmark’s P&T Committee, infused drugs,

most over-the-counter medications,

nutritional, vitamin and dietary

supplements, or antigen therapy. The

preceding list of excluded items is

illustrative only and is not a complete list of

items that are not eligible for the process.

Claims

WEB T94 80 Form Number: Wellmark IA Grp/CL_ 0121

Request for Benefit Exception Review If you have received an adverse benefit

determination that denies or reduces

benefits or fails to provide payment in whole

or in part for any of the following services,

when recommended by your treating

provider as medically necessary, you or an

individual acting as your authorized

representative may request a benefit

exception review.

Services subject to this exception process:

◼ For a woman who previously has had

breast cancer, ovarian cancer, or other

cancer, but who has not been diagnosed

with BRCA-related cancer, appropriate

preventive screening, genetic

counseling, and genetic testing.

◼ FDA-approved contraceptive items or

services prescribed by your health care

provider based upon a specific

determination of medical necessity for

you.

◼ For transgender individuals, sex-specific

preventive care services (e.g.,

mammograms and Pap smears) that his

or her attending provider has

determined are medically appropriate.

◼ For dependent children, certain well-

woman preventive care services that the

attending provider determined are age-

and developmentally-appropriate.

◼ Anesthesia services in connection with a

preventive colonoscopy when your

attending provider determined that

anesthesia would be medically

appropriate.

◼ A required consultation prior to a

screening colonoscopy, if your attending

provider determined that the pre-

procedure consultation would be

medically appropriate for you.

◼ If you received pathology services from

an in-network provider related to a

preventive colonoscopy screening for

which you were responsible for a portion

of the cost, such as a deductible,

copayment or coinsurance.

◼ Certain immunizations that ACIP

recommends for specified individuals

(rather than for routine use for an entire

population), when prescribed by your

health care provider consistent with the

ACIP recommendations.

◼ FDA-approved intrauterine devices and

implants, if prescribed by your health

care provider.

◼ Brand name drug when the generic

equivalent drug is available, if your

provider determines the brand name

drug is medically necessary and the

generic equivalent drug is medically

inappropriate.

You may request a benefit exception review

orally or in writing by submitting your

request to the address listed in the Appeals

section. To be considered, your request

must include supporting medical record

documentation and a letter or statement

from your treating provider that the services

or supplies were medically necessary and

your treating provider’s reason(s) for their

determination that the services or supplies

were medically necessary.

Your request will be addressed within the

timeframes outlined in the Appeals section

based upon whether your request is a

medically urgent or non-medically urgent

matter.

Form Number: Wellmark IA Grp/COB_ 0121 81 WEB T94

11. Coordination of Benefits

Coordination of benefits applies when you

have more than one plan, insurance policy,

or group health plan that provides the same

or similar benefits as this plan. Benefits

payable under this plan, when combined

with those paid under your other coverage,

will not be more than 100 percent of either

our payment arrangement amount or the

other plan’s payment arrangement amount.

The method we use to calculate the payment

arrangement amount may be different from

your other plan’s method.

In some instances, our claim payment

amount is based on a uniform payment per

patient, called capitation. When you receive

services payable by capitation and your

other carrier has primary payment

responsibility for covered services:

◼ We are not responsible for payment to

your health care provider beyond the

applicable capitation amount; and

◼ You are not responsible for copayment

amounts that would apply if coverage

under this medical benefits plan were

the primary coverage.

Other Coverage When you receive services, you must inform

us that you have other coverage, and inform

your health care provider about your other

coverage. Other coverage includes any of the

following:

◼ Group and nongroup insurance

contracts and subscriber contracts.

◼ HMO contracts.

◼ Uninsured arrangements of group or

group-type coverage.

◼ Group and nongroup coverage through

closed panel plans.

◼ Group-type contracts.

◼ The medical care components of long-

term contracts, such as skilled nursing

care.

◼ Medicare or other governmental

benefits (not including Medicaid).

◼ The medical benefits coverage of your

auto insurance (whether issued on a

fault or no-fault basis).

Coverage that is not subject to coordination

of benefits includes the following:

◼ Hospital indemnity coverage or other

fixed indemnity coverage.

◼ Accident-only coverage.

◼ Specified disease or specified accident

coverage.

◼ Limited benefit health coverage, as

defined by Iowa law.

◼ School accident-type coverage.

◼ Benefits for nonmedical components of

long-term care policies.

◼ Medicare supplement policies.

◼ Medicaid policies.

◼ Coverage under other governmental

plans, unless permitted by law.

You must cooperate with Wellmark and

provide requested information about other

coverage. Failure to provide information can

result in a denied claim. We may get the

facts we need from or give them to other

organizations or persons for the purpose of

applying the following rules and

determining the benefits payable under this

plan and other plans covering you. We need

not tell, or get the consent of, any person to

do this.

Your Network Provider will forward your

coverage information to us. If you see an

Out-of-Network Provider, you are

responsible for informing us about your

other coverage.

Claim Filing If you know that your other coverage has

primary responsibility for payment, after

you receive services or obtain a covered

prescription drug, a claim should be

submitted to your other insurance carrier

Coordination of Benefits

WEB T94 82 Form Number: Wellmark IA Grp/COB_ 0121

first. If that claim is processed with an

unpaid balance for benefits eligible under

this group health plan, you or your provider

should submit a claim to us and attach the

other carrier’s explanation of benefit

payment within 180 days of the date of the

other carrier's explanation of benefits. We

may contact your provider or the other

carrier for further information.

Rules of Coordination We follow certain rules to determine which

health plan or coverage pays first (as the

primary plan) when other coverage provides

the same or similar benefits as this group

health plan. Here are some of those rules:

◼ The primary plan pays or provides

benefits according to its terms of

coverage and without regard to the

benefits under any other plan. Except as

provided below, a plan that does not

contain a coordination of benefits

provision that is consistent with

applicable regulations is always primary

unless the provisions of both plans state

that the complying plan is primary.

◼ Coverage that is obtained by

membership in a group and is designed

to supplement a part of a basic package

of benefits is excess to any other parts of

the plan provided by the contract

holder. (Examples of such

supplementary coverage are major

medical coverage that is superimposed

over base plan hospital and surgical

benefits and insurance-type coverage

written in connection with a closed

panel plan to provide Out-of-Network

benefits.)

The following rules are to be applied in

order. The first rule that applies to your

situation is used to determine the primary

plan.

◼ The coverage that you have as an

employee, plan member, subscriber,

policyholder, or retiree pays before

coverage that you have as a spouse or

dependent. However, if the person is a

Medicare beneficiary and, as a result of

federal law, Medicare is secondary to the

plan covering the person as a dependent

and primary to the plan covering the

person as other than a dependent (e.g., a

retired employee), then the order of

benefits between the two plans is

reversed, so that the plan covering the

person as the employee, plan member,

subscriber, policyholder or retiree is the

secondary plan and the other plan is the

primary plan.

◼ The coverage that you have as the result

of active employment (not laid off or

retired) pays before coverage that you

have as a laid-off or retired employee.

The same would be true if a person is a

dependent of an active employee and

that same person is a dependent of a

retired or laid-off employee. If the other

plan does not have this rule and, as a

result, the plans do not agree on the

order of benefits, this rule is ignored.

◼ If a person whose coverage is provided

pursuant to COBRA or under a right of

continuation provided by state or other

federal law is covered under another

plan, the plan covering the person as an

employee, plan member, subscriber,

policyholder or retiree or covering the

person as a dependent of an employee,

member, subscriber or retiree is the

primary plan and the COBRA or state or

other federal continuation coverage is

the secondary plan. If the other plan

does not have this rule and, as a result,

the plans do not agree on the order of

benefits, this rule is ignored.

◼ The coverage with the earliest

continuous effective date pays first if

none of the rules above apply.

◼ Notwithstanding the preceding rules,

when you present your Blue Rx Value

Plus ID card to a pharmacy as the

primary payer, your Blue Rx Value Plus

prescription drug benefits are primary

for prescription drugs purchased at the

pharmacy. If, under the preceding rules,

your Blue Rx Value Plus prescription

drug benefits are secondary and you

present your Blue Rx Value Plus ID card



to a pharmacy as the secondary payer,

your Blue Rx Value Plus prescription

drug benefits are secondary for

prescription drugs purchased at the

pharmacy.

◼ If the preceding rules do not determine

the order of benefits and if the plans

cannot agree on the order of benefits

within 30 calendar days after the plans

have received all information needed to

pay the claim, the plans will pay the

claim in equal shares and determine

their relative liabilities following

payment. However, we will not pay more

than we would have paid had this plan

been primary.

Dependent Children To coordinate benefits for a dependent

child, the following rules apply (unless there

is a court decree stating otherwise):

◼ If the child is covered by both parents

who are married (and not separated) or

who are living together, whether or not

they have been married, then the

coverage of the parent whose birthday

occurs first in a calendar year pays first.

If both parents have the same birthday,

the plan that has covered the parent the

longest is the primary plan.

◼ For a child covered by separated or

divorced parents or parents who are not

living together, whether or not they have

been married:

⎯ If a court decree states that one of

the parents is responsible for the

child’s health care expenses or

coverage and the plan of that parent

has actual knowledge of those terms,

then that parent’s coverage pays

first. If the parent with responsibility

has no health care coverage for the

dependent child’s health care

expenses, but that parent’s spouse

does, that parent’s spouse’s coverage

pays first. This item does not apply

with respect to any plan year during

which benefits are paid or provided

before the entity has actual

knowledge of the court decree

provision.

⎯ If a court decree states that both

parents are responsible for the

child’s health care expense or health

care coverage or if a court decree

states that the parents have joint

custody without specifying that one

parent has responsibility for the

health care expenses or coverage of

the dependent child, then the

coverage of the parent whose

birthday occurs first in a calendar

year pays first. If both parents have

the same birthday, the plan that has

covered the parent the longest is the

primary plan.

⎯ If a court decree does not specify

which parent has financial or

insurance responsibility, then the

coverage of the parent with custody

pays first. The payment order for the

child is as follows: custodial parent,

spouse of custodial parent, other

parent, spouse of other parent. A

custodial parent is the parent

awarded custody by a court decree

or, in the absence of a court decree,

is the parent with whom the child

resides more than one-half of the

calendar year excluding any

temporary visitation.

◼ For a dependent child covered under

more than one plan of individuals who

are not the parents of the child, the

order of benefits shall be determined, as

applicable, as outlined previously in this

Dependent Children section.

◼ For a dependent child who has coverage

under either or both parents’ plans and

also has his or her own coverage as a

dependent under a spouse’s plan, the

plan that covered the dependent for the

longer period of time is the primary

plan. If the dependent child’s coverage

under the spouse’s plan began on the

same date as the dependent child’s

coverage under either or both parents’

plans, the order of benefits shall be

determined, as applicable, as outlined in


WEB T94 84 Form Number: Wellmark IA Grp/COB_ 0121

the first bullet of this Dependent

Children section, to the dependent

child’s parent or parents and the

dependent’s spouse.











been primary.

Coordination with Noncomplying Plans If you have coverage with another plan that

is excess or always secondary or that does

not comply with the preceding rules of

coordination, we may coordinate benefits on

the following basis:

◼ If this is the primary plan, we will pay its

benefits first.

◼ If this is the secondary plan, we will pay

benefits first, but the amount of benefits

will be determined as if this plan were

secondary. Our payment will be limited

to the amount we would have paid had

this plan been primary.

◼ If the noncomplying plan does not

provide information needed to

determine benefits, we will assume that

the benefits of the noncomplying plan

are identical to this plan and will

administer benefits accordingly. If we

receive the necessary information within

two years of payment of the claim, we

will adjust payments accordingly.

◼ In the event that the noncomplying plan

reduces its benefits so you receive less

than you would have received if we had

paid as the secondary plan and the

noncomplying plan was primary, we will

advance an amount equal to the

difference. In no event will we advance

more than we would have paid had this

plan been primary, minus any amount

previously paid. In consideration of the

advance, we will be subrogated to all of

your rights against the noncomplying

plan. See Subrogation, page 100.











been primary.

Effects on the Benefits of this Plan In determining the amount to be paid for

any claim, the secondary plan will calculate

the benefits it would have paid in the

absence of other coverage and apply the

calculated amount to any allowable expense

under its plan that is unpaid by the primary

plan. The secondary plan may then reduce

its payment by the amount so that, when

combined with the amount paid by the

primary plan, total benefits paid or provided

by all plans for the claim do not exceed the

total allowable expense for that claim. In

addition, the secondary plan will credit to its

applicable deductible any amounts it would

have credited to its deductible in the

absence of other coverage.

If a person is enrolled in two or more closed

panel plans and if, for any reason including

the provision of service by a non-panel

provider, benefits are not payable by one

closed panel plan, coordination of benefits

will not apply between that plan and other

closed panel plans.

Right of Recovery If the amount of payments made by us is

more than we should have paid under these

coordination of benefits provisions, we may

recover the excess from any of the persons

to or for whom we paid, or from any other

person or organization that may be

responsible for the benefits or services

provided for the covered person. The

amount of payments made includes the



reasonable cash value of any benefits

provided in the form of services.

Plans That Provide Benefits as Services A secondary plan that provides benefits in

the form of services may recover the

reasonable cash value of the service from

the primary plan, to the extent benefits for

the services are covered by the primary plan

and have not already been paid or provided

by the primary plan.

Coordination with Medicare Medicare is by law the secondary coverage

to group health plans in a variety of

situations.

The following provisions apply only if you

have both Medicare and employer group

health coverage and meet the specific

Medicare Secondary Payer provisions for

the applicable Medicare entitlement reason.

Medicare Part B Drugs Drugs paid under Medicare Part B are

covered under the medical benefits of this

plan.

Working Aged If you are a member of a group health plan

of an employer with at least 20 employees

for each working day for at least 20 calendar

weeks in the current or preceding year, then

in most situations Medicare is the secondary

payer if the beneficiary is:

◼ Age 65 or older; and

◼ A current employee or spouse of a

current employee covered by an

employer group health plan.

Working Disabled If you are a member of a group health plan

of an employer with at least 100 full-time,

part-time, or leased employees on at least

50 percent of regular business days during

the preceding calendar year, then in most

situations Medicare is the secondary payer if

the beneficiary is:

◼ Under age 65;

◼ A recipient of Medicare disability

benefits; and

◼ A current employee or a spouse or

dependent of a current employee,

covered by an employer group health

plan.

End-Stage Renal Disease (ESRD) The ESRD requirements apply to group

health plans of all employers, regardless of

the number of employees. Under these

requirements, Medicare is the secondary

payer during the first 30 months of

Medicare eligibility if both of the following

are true:

◼ The beneficiary is eligible for Medicare

coverage as an ESRD patient; and

◼ The beneficiary is covered by an

employer group health plan.

If the beneficiary is already covered by

Medicare due to age or disability and the

beneficiary becomes eligible for Medicare

ESRD coverage, Medicare generally is the

secondary payer during the first 30 months

of ESRD eligibility. However, if the group

health plan is secondary to Medicare (based

on other Medicare secondary-payer

requirements) at the time the beneficiary

becomes eligible for ESRD, the group health

plan remains secondary to Medicare.

This is only a general summary of the laws.

For complete information, contact your

employer or the Social Security

Administration.

Form Number: Wellmark IA Grp/AP_ 0121 87 WEB T94

12. Appeals

Right of Appeal You have the right to one full and fair review

in the case of an adverse benefit

determination that denies, reduces, or

terminates benefits, or fails to provide

payment in whole or in part. Adverse benefit

determinations include a denied or reduced

claim, a rescission of coverage, or an

adverse benefit determination concerning a

pre-service notification requirement. Pre-

service notification requirements are:

◼ A precertification request.

◼ A notification of admission or services.

◼ A prior approval request.

◼ A prior authorization request for

prescription drugs.

How to Request an Internal Appeal You or your authorized representative, if

you have designated one, may appeal an

adverse benefit determination within 180

days from the date you are notified of our

adverse benefit determination by

submitting a written appeal. Appeal forms

are available at our website, Wellmark.com.

See Authorized Representative, page 95.

Medically Urgent Appeal To appeal an adverse benefit determination

involving a medically urgent situation, you

may request an expedited appeal, either

orally or in writing. Medically urgent

generally means a situation in which your

health may be in serious jeopardy or, in the

opinion of your physician, you may

experience severe pain that cannot be

adequately controlled while you wait for a

decision.

Non-Medically Urgent Appeal To appeal an adverse benefit determination

that is not medically urgent, you must make

your request for a review in writing.

What to Include in Your Internal Appeal You must submit all relevant information

with your appeal, including the reason for

your appeal. This includes written

comments, documents, or other information

in support of your appeal. You must also

submit:

◼ Date of your request.

◼ Your name (please type or print),

address, and if applicable, the name and

address of your authorized

representative.

◼ Member identification number.

◼ Claim number from your Explanation of

Benefits, if applicable.

◼ Date of service in question.

For a prescription drug appeal, you

also must submit:

◼ Name and phone number of the

pharmacy.

◼ Name and phone number of the

practitioner who wrote the prescription.

◼ A copy of the prescription.

◼ A brief description of your medical

reason for needing the prescription.

If you have difficulty obtaining this

information, ask your provider or

pharmacist to assist you.

Where to Send Internal Appeal


Special Inquiries

P.O. Box 9232, Station 5W189


Review of Internal Appeal Your request for an internal appeal will be

reviewed only once. The review will take

into account all information regarding the

adverse benefit determination whether or

not the information was presented or

Appeals

WEB T94 88 Form Number: Wellmark IA Grp/AP_ 0121

available at the initial determination. Upon

request, and free of charge, you will be

provided reasonable access to and copies of

all relevant records used in making the

initial determination. Any new information

or rationale gathered or relied upon during

the appeal process will be provided to you

prior to Wellmark issuing a final adverse

benefit determination and you will have the

opportunity to respond to that information

or to provide information.

The review will not be conducted by the

original decision makers or any of their

subordinates. The review will be conducted

without regard to the original decision. If a

decision requires medical judgment, we will

consult an appropriate medical expert who

was not previously involved in the original

decision and who has no conflict of interest

in making the decision. If we deny your

appeal, in whole or in part, you may request,

in writing, the identity of the medical expert

we consulted.

Decision on Internal Appeal The decision on appeal is the final internal

determination. Once a decision on internal

appeal is reached, your right to internal

appeal is exhausted.

Medically Urgent Appeal For a medically urgent appeal, you will be

notified (by telephone, e-mail, fax or

another prompt method) of our decision as

soon as possible, based on the medical

situation, but no later than 72 hours after

your expedited appeal request is received. If

the decision is adverse, a written

notification will be sent.

All Other Appeals For all other appeals, you will be notified in

writing of our decision. Most appeal

requests will be determined within 30 days

and all appeal requests will be determined

within 60 days.

External Review You have the right to request an external

review of a final adverse determination

involving a covered service when the

determination involved:

◼ Medical necessity.

◼ Appropriateness of services or supplies,

including health care setting, level of

care, or effectiveness of treatment.

◼ Investigational or experimental services

or supplies.

◼ Concurrent review or admission to a

facility. See Notification Requirements

and Care Coordination, page 53.

◼ A rescission of coverage.

An adverse determination eligible for

external review does not include a denial of

coverage for a service or treatment

specifically excluded under this plan.

The external review will be conducted by

independent health care professionals who

have no association with us and who have

no conflict of interest with respect to the

benefit determination.

Have you exhausted the appeal

process? Before you can request an

external review, you must first exhaust the

internal appeal process described earlier in

this section. However, if you have not

received a decision regarding the adverse

benefit determination within 30 days

following the date of your request for an

appeal, you are considered to have

exhausted the internal appeal process.

Requesting an external review. You or

your authorized representative may request

an external review through the Iowa

Insurance Division by completing an

External Review Request Form and

submitting the form as described in this

section. You may obtain this request form

by calling the Customer Service number on

your ID card, by visiting our website at

Wellmark.com, by contacting the Iowa

Insurance Division, or by visiting the Iowa

Insurance Division's website at

www.iid.iowa.gov.

You will be required to authorize the release

of any medical records that may be required

http://www.iid.iowa.gov/

Appeals

Form Number: Wellmark IA Grp/AP_ 0121 89 WEB T94

to be reviewed for the purpose of reaching a

decision on your request for external review.

Requests must be filed in writing at the

following address, no later than four months

after you receive notice of the final adverse

benefit determination:

Iowa Insurance Division

1963 Bell Avenue, Suite 100

Des Moines, IA 50315

Fax: 515-654-6500

E-mail:

[email protected]

How the review works. Upon

notification that an external review request

has been filed, Wellmark will make a

preliminary review of the request to

determine whether the request may proceed

to external review. Following that review,

the Iowa Insurance Division will decide

whether your request is eligible for an

external review, and if it is, the Iowa

Insurance Division will assign an

independent review organization (IRO) to

conduct the external review. You will be

advised of the name of the IRO and will

then have five business days to provide new

information to the IRO. The IRO will make

a decision within 45 days of the date the

Iowa Insurance Division receives your

request for an external review.

Need help? You may contact the Iowa

Insurance Division at 877-955-1212 at any

time for assistance with the external review

process.

Expedited External Review You do not need to exhaust the internal

appeal process to request an external review

of an adverse determination or a final

adverse determination if you have a medical

condition for which the time frame for

completing an internal appeal or for

completing a standard external review

would seriously jeopardize your life or

health or would jeopardize your ability to

regain maximum function.

You may also have the right to request an

expedited external review of a final adverse

determination that concerns an admission,

availability of care, concurrent review, or

service for which you received emergency

services, and you have not been discharged

from a facility.

If our adverse benefit determination is that

the service or treatment is investigational or

experimental and your treating physician

has certified in writing that delaying the

service or treatment would render it

significantly less effective, you may also

have the right to request an expedited

external review.

You or your authorized representative may

submit an oral or written expedited external

review request to the Iowa Insurance

Division by contacting the Iowa Insurance

Division at 877-955-1212.

If the Insurance Division determines the

request is eligible for an expedited external

review, the Division will immediately assign

an IRO to conduct the review and a decision

will be made expeditiously, but in no event

more than 72 hours after the IRO receives

the request for an expedited external review.

Arbitration and Legal Action You shall not start arbitration or legal action

against us until you have exhausted the

appeal procedure described in this section.

See the Arbitration and Legal Action

section and Governing Law, page 100, for

important information about your

arbitration and legal action rights after you

have exhausted the appeal procedures in

this section.

Form Number: Wellmark IA Grp/ALA_ 0121 91 WEB T94

13. Arbitration and Legal Action

PLEASE READ THIS SECTION

CAREFULLY

Mandatory Arbitration You shall not start an action against us on

any Claims (as defined below) unless you

have first exhausted the appeal processes

described in the Appeals section of this

coverage manual.

Except as solely discussed below, this

section provides that Claims must be

resolved by binding mandatory arbitration.

Arbitration replaces the right to go to court,

have a jury trial or initiate or participate in a

class action. In arbitration, disputes are

resolved by an arbitrator, not a judge or a

jury. Arbitration procedures are simpler and

more limited than in court.

Covered Claims Except as solely stated below, you or we

must arbitrate any claim, dispute or

controversy arising out of or related to this

coverage manual or any other document

related to your health plan, including, but

not limited to, member eligibility, benefits

under your health plan or administration of

your health plan (any and/or all of the

foregoing called “Claims”).

Except as stated below, all Claims are

subject to mandatory arbitration, no matter

what legal theory they are based, whether in

law or equity, upon or what remedy

(damages, or injunctive or declaratory

relief) they seek, including Claims based on

contract, tort (including intentional tort),

fraud, agency, your or our negligence,

statutory or regulatory provisions, or any

other sources of law; counterclaims, cross-

claims, third-party claims, interpleaders or

otherwise; Claims made regarding past,

present or future conduct; and Claims made

independently or with other claims. This

also includes Claims made by or against

anyone connected with us or you or

claiming through us or you, or by someone

making a claim through us or you, such as a

covered family member, employee, agent,

representative, or an affiliated or subsidiary

company. For purposes of this Arbitration

and Legal Action section, the words “we,”

“us,” and “our” refer to Wellmark, Inc., and

its subsidiaries and affiliates, the plan

sponsor and/or the plan administrator, as

well as their respective directors, officers,

employees and agents.

No Class Arbitrations and Class Actions Waiver YOU UNDERSTAND AND AGREE THAT

YOU AND WE BOTH ARE VOLUNTARILY

AND IRREVOCABLY WAIVING THE

RIGHT TO PURSUE OR HAVE A DISPUTE

RESOLVED AS A PLAINTIFF OR CLASS

MEMBER IN ANY PURPORTED CLASS,

COLLECTIVE OR REPRESENTATIVE

PROCEEDING PENDING BETWEEN YOU

AND US. YOU ARE AGREEING TO GIVE

UP THE ABILITY TO PARTICIPATE IN

CLASS ARBITRATIONS, CLASS ACTIONS

AND ANY OTHER COLLECTIVE OR

REPRESENTATIVE ACTIONS. Neither you

nor we consent to the incorporation of the

AAA Supplementary Rules for Class

Arbitration into the rules governing the

arbitration of Claims. The arbitrator has no

authority to arbitrate any claim on a class or

representative basis and may award relief

only on an individual basis. Claims of two or

more persons may not be combined in the

same arbitration, unless both you and we

agree to do so.

Claims Excluded from Mandatory Arbitration ◼ Small Claims – individual Claims filed

in a small claims court are not subject to

arbitration, as long as the matter stays

in small claims court.

◼ Claims Excluded By Applicable Law –

federal or state law may exempt certain

Claims from mandatory arbitration. IF

Arbitration and Legal Action

WEB T94 92 Form Number: Wellmark IA Grp/ALA_ 0121

AN ARBITRATOR DETERMINES A

PARTICULAR CLAIM IS

EXCLUDED FROM ARBITRATION

BY FEDERAL OR STATE LAW,

CLAIMS EXCLUDED BY

APPLICABLE LAW, LATER IN

THIS SECTION, AND GOVERNING

LAW, PAGE 100, WILL APPLY TO

THE PARTIES AND SUCH

PARTICULAR CLAIM.

Arbitration Process Generally ◼ No demand for arbitration of a Claim

because of a health benefit claim under

this plan, or because of the alleged

breach of this plan, shall be made more

than two years after the end of the

calendar year in which the services or

supplies were provided.

◼ Arbitration shall be conducted by the

American Arbitration Association

(“AAA”) according to the Federal

Arbitration Act (“FAA”) (to the exclusion

of any state laws inconsistent

therewith), this arbitration provision

and the applicable AAA Consumer

Arbitration Rules in effect when the

Claim is filed (“AAA Rules”), except

where those rules conflict with this

arbitration provision. You can obtain

copies of the AAA Rules at the AAA’s

website (www.adr.org). You or we may

choose to have a hearing, appear at any

hearing by phone or other electronic

means, and/or be represented by

counsel. Any in-person hearing will be

held in the same city as the U.S. District

Court closest to your billing address.

◼ Either you or we may apply to a court

for emergency, temporary or

preliminary injunctive relief or an order

in aid of arbitration (i) prior to the

appointment of an arbitrator or (ii) after

the arbitrator makes a final award and

closes the arbitration. Once an arbitrator

has been appointed until the arbitration

is closed, emergency, temporary or

preliminary injunctive relief may only be

granted by the arbitrator. Either you or

we may apply to a court for enforcement

of any emergency, temporary or

preliminary injunctive relief granted by

the arbitrator.

◼ Arbitration may be compelled at any

time by either party, even where there is

a pending lawsuit in court, unless a trial

has begun or a final judgment has been

entered. Neither you nor we waive the

right to arbitrate by filing or serving a

complaint, answer, counterclaim,

motion, or discovery in a court lawsuit.

To invoke arbitration, a party may file a

motion to compel arbitration in a

pending matter and/or commence

arbitration by submitting the required

AAA forms and requisite filing fees to

the AAA.

◼ The arbitration shall be conducted by a

single arbitrator in accordance with this

arbitration provision and the AAA

Rules, which may limit discovery. The

arbitrator shall not apply any federal or

state rules of civil procedure for

discovery, but the arbitrator shall honor

claims of privilege recognized at law and

shall take reasonable steps to protect

plan information and other confidential

information of either party if requested

to do so. The parties agree that the scope

of discovery will be limited to non-

privileged information that is relevant to

the Claim, and consistent with the

parties’ intent, the arbitrator shall

ensure that allowed discovery is

reasonable in scope, cost-effective and

non-onerous to either party. The

arbitrator shall apply the FAA and other

applicable substantive law not

inconsistent with the FAA, and may

award damages or other relief under

applicable law.

◼ The arbitrator shall make any award in

writing and, if requested by you or us,

may provide a brief written statement of

the reasons for the award. An arbitration

award shall decide the rights and

obligations only of the parties named in

the arbitration and shall not have any

bearing on any other person or dispute.

http://www.adr.org/


Form Number: Wellmark IA Grp/ALA_ 0121 93 WEB T94

IF ARBITRATION IS INVOKED BY

ANY PARTY WITH RESPECT TO A

CLAIM, NEITHER YOU NOR WE

WILL HAVE THE RIGHT TO

LITIGATE THAT CLAIM IN COURT

OR HAVE A JURY TRIAL ON THAT

CLAIM, OR TO ENGAGE IN

PREARBITRATION DISCOVERY

EXCEPT AS PROVIDED FOR IN THE

APPLICABLE ARBITRATION RULES.

THE ARBITRATOR’S DECISION

WILL BE FINAL AND BINDING. YOU

UNDERSTAND THAT OTHER

RIGHTS THAT YOU WOULD HAVE IF

YOU WENT TO COURT MAY ALSO

NOT BE AVAILABLE IN

ARBITRATION.

Arbitration Fees and Other Costs The AAA Rules determine what costs you

and we will pay to the AAA in connection

with the arbitration process. In most

instances, your responsibility for filing,

administrative and arbitrator fees to pursue

a Claim in arbitration will not exceed $200.

However, if the arbitrator decides that

either the substance of your claim or the

remedy you asked for is frivolous or brought

for an improper purpose, the arbitrator will

use the AAA Rules to determine whether

you or we are responsible for the filing,

administrative and arbitrator fees.

You may wish to consult with or be

represented by an attorney during the

arbitration process. Each party is

responsible for its own attorney’s fees and

other expenses, such as witness fees and

expert witness costs.

Confidentiality The arbitration proceedings and arbitration

award shall be maintained by the parties as

strictly confidential, except as is otherwise

required by court order, as is necessary to

confirm, vacate or enforce the award, and

for disclosure in confidence to the parties’

respective attorneys and tax advisors of a

party who is an individual.

Questions of Arbitrability You and we mutually agree that the

arbitrator, and not a court, will decide in the

first instance all questions of substantive

arbitrability, including without limitation

the validity of this Section, whether you and

we are bound by it, and whether this Section

applies to a particular Claim.

Claims Excluded By Applicable Law If an arbitrator determines a particular

Claim is excluded from arbitration by

federal or state law, you and we agree that

the following terms will apply to any legal or

equitable action brought in court because of

such Claim:

◼ You shall not bring any legal or

equitable action against us because of a

health benefit claim under this plan, or

because of the alleged breach of this

plan, more than two years after the end

of the calendar year in which the

services or supplies were provided.

◼ Any action brought because of a Claim

under this plan will be litigated in the

state or federal courts located in the

state of Iowa and in no other.

◼ YOU AND WE BOTH WAIVE ANY

RIGHT TO A JURY TRIAL WITH

RESPECT TO AND IN ANY CLAIM.

◼ FURTHER, YOU AND WE BOTH

WAIVE ANY RIGHT TO SEEK OR

RECOVER PUNITIVE OR

EXEMPLARY DAMAGES WITH

RESPECT TO ANY CLAIM.

Survival and Severability of Terms This Arbitration and Legal Action section

will survive termination of the plan. If any

portion of this provision is deemed invalid

or unenforceable under any law or statute it

will not invalidate the remaining portions of

this Arbitration and Legal Action section or

the plan. To the extent a Claim qualifies for

mandatory arbitration and there is a conflict

or inconsistency between the AAA Rules


WEB T94 94 Form Number: Wellmark IA Grp/ALA_ 0121

and this Arbitration and Legal Action

section, this Arbitration and Legal Action

section will govern.

Form Number: Wellmark IA Grp/GP_ 0121 95 WEB T94

14. General Provisions

Contract The conditions of your coverage are defined

in your contract. Your contract includes:

◼ Any application you submitted to us or

to the University of Iowa.

◼ Any agreement or group policy we have

with the University of Iowa.

◼ Any application completed by the

University of Iowa.

◼ This coverage manual and any

amendments.

All of the statements made by you or the

University of Iowa in any of these materials

will be treated by us as representations, not

warranties.

Interpreting this Coverage Manual We will interpret the provisions of this

coverage manual and determine the answer

to all questions that arise under it. We have

the administrative discretion to determine

whether you meet our written eligibility

requirements, or to interpret any other term

in this coverage manual. If any benefit

described in this coverage manual is subject

to a determination of medical necessity,

unless otherwise required by law, we will

make that factual determination. Our

interpretations and determinations are final

and conclusive, subject to the appeal

procedures outlined earlier in this coverage

manual.

There are certain rules you must follow in

order for us to properly administer your

benefits. Different rules appear in different

sections of your coverage manual. You

should become familiar with the entire

document.

Plan Year The Plan Year has been designated and

communicated to Wellmark by your group

health plan’s plan sponsor or plan

administrator as the twelve month period

commencing on the effective date of your

group health plan's annual renewal with

Wellmark.

Authority to Terminate, Amend, or Modify The University of Iowa has the authority to

terminate, amend, or modify the coverage

described in this coverage manual at any

time. Any amendment or modification will

be in writing and will be as binding as this

coverage manual. If your contract is

terminated, you may not receive benefits.

Authorized Group Benefits Plan Changes No agent, employee, or representative of

ours is authorized to vary, add to, change,

modify, waive, or alter any of the provisions

described in this coverage manual. This

coverage manual cannot be changed except

by one of the following:

◼ Written amendment signed by an

authorized officer and accepted by you

or the University of Iowa.

◼ Our receipt of proper notification that

an event has changed your spouse or

dependent's eligibility for coverage. See

Coverage Changes and Termination,

page 71.

Member Participation Information will be made available to

members regarding matters such as

wellness, general health education, and

matters of policy and operation of Wellmark

Health Plan of Iowa, Inc.

Authorized Representative You may authorize another person to

represent you and with whom you want us

to communicate regarding specific claims or

an appeal. This authorization must be in

writing, signed by you, and include all the

information required in our Authorized

General Provisions

WEB T94 96 Form Number: Wellmark IA Grp/GP_ 0121

Representative Form. This form is available

at Wellmark.com or by calling the Customer

Service number on your ID card.

In a medically urgent situation your treating

health care practitioner may act as your

authorized representative without

completion of the Authorized

Representative Form.

An assignment of benefits, release of

information, or other similar form that you

may sign at the request of your health care

provider does not make your provider an

authorized representative. You may

authorize only one person as your

representative at a time. You may revoke the

authorized representative at any time.

Release of Information By enrolling in this group health plan, you

have agreed to release any necessary

information requested about you so we can

process claims for benefits.

You must allow any provider, facility, or

their employee to give us information about

a treatment or condition. If we do not

receive the information requested, or if you

withhold information, your benefits may be

denied. If you fraudulently use your

coverage or misrepresent or conceal

material facts when providing information,

then we may terminate your coverage under


Privacy of Information The University of Iowa is required to protect

the privacy of your health information. It is

required to request, use, or disclose your

health information only as permitted or

required by law. For example, the University

of Iowa has contracted with Wellmark to

administer this group health plan and

Wellmark will use or disclose your health

information for treatment, payment, and

health care operations according to the

standards and specifications of the federal

privacy regulations.

Treatment We may disclose your health information to

a physician or other health care provider in

order for such health care provider to

provide treatment to you.

Payment We may use and disclose your health

information to pay for covered services from

physicians, hospitals, and other providers,

to determine your eligibility for benefits, to

coordinate benefits, to determine medical

necessity, to obtain payment from the

University of Iowa, to issue explanations of

benefits to the person enrolled in the group

health plan in which you participate, and

the like. We may disclose your health

information to a health care provider or

entity subject to the federal privacy rules so

they can obtain payment or engage in these

payment activities.

Health Care Operations We may use and disclose your health

information in connection with health care

operations. Health care operations include,

but are not limited to, determining payment

and rates for your group health plan; quality

assessment and improvement activities;

reviewing the competence or qualifications

of health care practitioners, evaluating

provider performance, conducting training

programs, accreditation, certification,

licensing, or credentialing activities;

medical review, legal services, and auditing,

including fraud and abuse detection and

compliance; business planning and

development; and business management

and general administrative activities.

Other Disclosures The University of Iowa or Wellmark is

required to obtain your explicit

authorization for any use or disclosure of

your health information that is not

permitted or required by law. For example,

we may release claim payment information

to a friend or family member to act on your

behalf during a hospitalization if you submit

an authorization to release information to

that person. If you give us an authorization,

General Provisions


you may revoke it in writing at any time.

Your revocation will not affect any use or

disclosures permitted by your authorization

while it was in effect.

Member Health Support Services Wellmark may from time to time make

available to you certain health support

services (such as disease management), for

a fee or for no fee. Wellmark may offer

financial and other incentives to you to use

such services. As a part of the provision of

these services, Wellmark may:

◼ Use your personal health information

(including, but not limited to, substance

abuse, mental health, and HIV/AIDS

information); and

◼ Disclose such information to your health

care providers and Wellmark’s health

support service vendors, for purposes of

providing such services to you.

Wellmark will use and disclose information

according to the terms of our Privacy

Practices Notice, which is available upon

request or at Wellmark.com.

Value Added or Innovative Benefits Wellmark may, from time to time, make

available to you certain value added or

innovative benefits for a fee or for no fee.

Examples include Blue365®, identity theft

protections, and discounts on

alternative/preventive therapies, fitness,

exercise and diet assistance, and elective

procedures as well as resources to help you

make more informed health decisions.

Wellmark may also provide rewards or

incentives under this plan if you participate

in certain voluntary wellness activities or

programs that encourage healthy behaviors.

Your employer is responsible for any

income and employment tax withholding,

depositing and reporting obligations that

may apply to the value of such rewards and

incentives.

Value-Based Programs Value-based programs involve local health

care organizations that are held accountable

for the quality and cost of care delivered to a

defined population. Value-based programs

can include accountable care organizations

(ACOs), patient centered medical homes

(PCMHs), and other programs developed by

Wellmark, the Blue Cross Blue Shield

Association, or other Blue Cross Blue Shield

health plans (“Blue Plans”). Wellmark and

Blue Plans have entered into collaborative

arrangements with value-based programs

under which the health care providers

participating in them are eligible for

financial incentives relating to quality and

cost-effective care of Wellmark and/or Blue

Plan members. If your physician, hospital,

or other health care provider participates in

the Wellmark ACO program or other value-

based program, Wellmark may make

available to such health care providers your

health care information, including claims

information, for purposes of helping

support their delivery of health care services

to you.

Health Insurance Portability and Accountability Act of 1996

Group Sponsor’s Certification of Compliance Your group health plan, any business

associate servicing your group health plan,

or Wellmark will not disclose protected

health information to your group sponsor

unless your group sponsor certifies that

group health plan documents have been

modified to incorporate this provision and

agrees to abide by this provision. Your

receipt of this coverage manual means that

your group sponsor has modified your

group health plan documents to incorporate

this provision, and has provided

certification of compliance to Wellmark.

General Provisions


Purpose of Disclosure to Group Sponsor Your group health plan, any business

associate servicing your group health plan,

or Wellmark will disclose protected health

information to your group sponsor only to

permit the group sponsor to perform plan

administration of the group health plan

consistent with the requirements of the

Health Insurance Portability and

Accountability Act of 1996 and its

implementing regulations (45 C.F.R. Parts

160-64). Any disclosure to and use by your

group sponsor of protected health

information will be subject to and consistent

with the provisions identified under

Restrictions on Group Sponsor’s Use and

Disclosure of Protected Health Information

and Adequate Separation Between the

Group Sponsor and the Group Health Plan,


Neither your group health plan, nor

Wellmark, or any business associate

servicing your group health plan will

disclose protected health information to

your group sponsor unless the disclosures

are explained in the Notice of Privacy

Practices distributed to plan members.

Neither your group health plan, nor

Wellmark, or any business associate

servicing your group health plan will

disclose protected health information to

your group sponsor for the purpose of

employment-related actions or decisions or

in connection with any other benefit or

employee benefit plan of the group sponsor.

Restrictions on Group Sponsor’s Use and Disclosure of Protected Health Information Your group sponsor will not use or further

disclose protected health information,

except as permitted or required by this

provision, or as required by law.

Your group sponsor will ensure that any

agent, including any subcontractor, to

whom it provides protected health

information, agrees to the restrictions and

conditions of this provision with respect to

protected health information and electronic

protected health information.

Your group sponsor will not use or disclose

protected health information for

employment-related actions or decisions or

in connection with any other benefit or

employee benefit plan of the group sponsor.

Your group sponsor will report to the group

health plan, any use or disclosure of

protected health information that is

inconsistent with the uses and disclosures

stated in this provision promptly upon

learning of such inconsistent use or

disclosure.

Your group sponsor will make protected

health information available to plan

members in accordance with 45 Code of

Federal Regulations §164.524.

Your group sponsor will make protected

health information available, and will on

notice amend protected health information,

in accordance with 45 Code of Federal

Regulations §164.526.

Your group sponsor will track disclosures it

may make of protected health information

so that it can provide the information

required by your group health plan to

account for disclosures in accordance with

45 Code of Federal Regulations §164.528.

Your group sponsor will make its internal

practices, books, and records relating to its

use and disclosure of protected health

information available to your group health

plan, and to the U.S. Department of Health

and Human Services to determine

compliance with 45 Code of Federal

Regulations Parts 160-64.

When protected health information is no

longer needed for the plan administrative

functions for which the disclosure was

made, your group sponsor will, if feasible,

return or destroy all protected health

information, in whatever form or medium

received from the group health plan,

including all copies of any data or

compilations derived from and/or revealing

member identity. If it is not feasible to

General Provisions


return or destroy all of the protected health

information, your group sponsor will limit

the use or disclosure of protected health

information it cannot feasibly return or

destroy to those purposes that make the

return or destruction of the information

infeasible.

Your group sponsor will implement

administrative, physical, and technical

safeguards that reasonably and

appropriately protect the confidentiality,

integrity, and availability of electronic

protected health information.

Your group sponsor will promptly report to

the group health plan any of the following

incidents of which the group sponsor

becomes aware:

◼ unauthorized access, use, disclosure,

modification, or destruction of the group

health plan’s electronic protected health

information, or

◼ unauthorized interference with system

operations in group sponsor’s

information systems that contain or

provide access to group health plan’s

electronic protected health information.

Adequate Separation Between the Group Sponsor and the Group Health Plan Certain individuals under the control of

your group sponsor may be given access to

protected health information received from

the group health plan, a business associate

servicing the group health plan, or

Wellmark. This class of employees will be

identified by the group sponsor to the group

health plan and Wellmark from time to time

as required under 45 Code of Federal

Regulations §164.504. These individuals

include all those who may receive protected

health information relating to payment

under, health care operations of, or other

matters pertaining to the group health plan

in the ordinary course of business.

These individuals will have access to

protected health information only to

perform the plan administration functions

that the group sponsor provides for the

group health plan.

Individuals granted access to protected

health information will be subject to

disciplinary action and sanctions, including

loss of employment or termination of

affiliation with the group sponsor, for any

use or disclosure of protected health

information in violation of or

noncompliance with this provision. The

group sponsor will promptly report such

violation or noncompliance to the group

health plan, and will cooperate with the

group health plan to correct the violation or

noncompliance, to impose appropriate

disciplinary action or sanctions on each

employee causing the violation or

noncompliance, and to mitigate any

negative effect the violation or

noncompliance may have on the member,

the privacy of whose protected health

information may have been compromised

by the violation or noncompliance.

Your group sponsor will ensure that these

provisions for adequate separation between

the group sponsor and the group health

plan are supported by reasonable and

appropriate security measures.

Nonassignment Except as required by law, benefits for

covered services under this group health

plan are for your personal benefit and

cannot be transferred or assigned to anyone

else without our consent. Whether made

before or after services are provided, you are

prohibited from assigning any claim. You

are further prohibited from assigning any

cause of action arising out of or relating to

this group health plan. Any attempt to

assign this group health plan, even if

assignment includes the provider’s rights to

receive payment, will be null and void.

Nothing contained in this group health plan

shall be construed to make the health plan

or Wellmark liable to any third party to

whom a member may be liable for medical

care, treatment, or services.

General Provisions


Governing Law To the extent not superseded by the laws of

the United States, the group health plan will

be construed in accordance with and

governed by the laws of the state of Iowa.

Medicaid Enrollment and Payments to Medicaid

Assignment of Rights This group health plan will provide payment

of benefits for covered services to you, your

beneficiary, or any other person who has

been legally assigned the right to receive

such benefits under requirements

established pursuant to Title XIX of the

Social Security Act (Medicaid).

Enrollment Without Regard to Medicaid Your receipt or eligibility for medical

assistance under Title XIX of the Social

Security Act (Medicaid) will not affect your

enrollment as a participant or beneficiary of

this group health plan, nor will it affect our

determination of any benefits paid to you.

Acquisition by States of Rights of Third Parties If payment has been made by Medicaid and

Wellmark has a legal obligation to provide

benefits for those services, Wellmark will

make payment of those benefits in

accordance with any state law under which a

state acquires the right to such payments.

Medicaid Reimbursement When a Network Provider submits a claim

to a state Medicaid program for a covered

service and Wellmark reimburses the state

Medicaid program for the service,

Wellmark’s total payment for the service

will be limited to the amount paid to the

state Medicaid program. No additional

payments will be made to the provider or to

you.

Subrogation For purposes of this “Subrogation” section,

“third party” includes, but is not limited to,

any of the following:

◼ The responsible person or that person’s

insurer;

◼ Uninsured motorist coverage;

◼ Underinsured motorist coverage;

◼ Personal umbrella coverage;

◼ Other insurance coverage including, but

not limited to, homeowner’s, motor

vehicle, or medical payments insurance;

and

◼ Any other payment from a source

intended to compensate you for injuries

resulting from an accident or alleged

negligence.

Right of Subrogation If you or your legal representative have a

claim to recover money from a third party

and this claim relates to an illness or injury

for which this group health plan provides

benefits, we, on behalf of the University of

Iowa, will be subrogated to you and your

legal representative’s rights to recover from

the third party as a condition to your receipt

of benefits.

Right of Reimbursement If you have an illness or injury as a result of

the act of a third party or arising out of

obligations you have under a contract and

you or your legal representative files a claim

under this group health plan, as a condition

of receipt of benefits, you or your legal

representative must reimburse us for all

benefits paid for the illness or injury from

money received from the third party or its

insurer, or under the contract, to the extent

of the amount paid by this group health plan

on the claim.

Once you receive benefits under this group

health plan arising from an illness or injury,

we will assume any legal rights you have to

collect compensation, damages, or any other

payment related to the illness or injury from

any third party.

You agree to recognize our rights under this

group health plan to subrogation and

reimbursement. These rights provide us

with a priority over any money paid by a

third party to you relative to the amount

General Provisions


paid by this group health plan, including

priority over any claim for nonmedical

charges, or other costs and expenses. We

will assume all rights of recovery, to the

extent of payment made under this group

health plan, regardless of whether payment

is made before or after settlement of a third

party claim, and regardless of whether you

have received full or complete

compensation for an illness or injury.

Procedures for Subrogation and Reimbursement You or your legal representative must do

whatever we request with respect to the

exercise of our subrogation and

reimbursement rights, and you agree to do

nothing to prejudice those rights. In

addition, at the time of making a claim for

benefits, you or your legal representative

must inform us in writing if you have an

illness or injury caused by a third party or

arising out of obligations you have under a

contract. You or your legal representative

must provide the following information, by

registered mail, as soon as reasonably

practicable of such illness or injury to us as

a condition to receipt of benefits:

◼ The name, address, and telephone

number of the third party that in any

way caused the illness or injury or is a

party to the contract, and of the attorney

representing the third party;

◼ The name, address and telephone

number of the third party’s insurer and

any insurer of you;

◼ The name, address and telephone

number of your attorney with respect to

the third party’s act;

◼ Prior to the meeting, the date, time and

location of any meeting between the

third party or his attorney and you, or

your attorney;

◼ All terms of any settlement offer made

by the third party or his insurer or your

insurer;

◼ All information discovered by you or

your attorney concerning the insurance

coverage of the third party;

◼ The amount and location of any money

that is recovered by you from the third

party or his insurer or your insurer, and

the date that the money was received;

◼ Prior to settlement, all information

related to any oral or written settlement

agreement between you and the third

party or his insurer or your insurer;

◼ All information regarding any legal

action that has been brought on your

behalf against the third party or his

insurer; and

◼ All other information requested by us.

Send this information to:


1331 Grand Avenue, Station 5W580


You also agree to all of the following:

◼ You will immediately let us know about

any potential claims or rights of recovery

related to the illness or injury.

◼ You will furnish any information and

assistance that we determine we will

need to enforce our rights under this

group health plan.

◼ You will do nothing to prejudice our

rights and interests including, but not

limited to, signing any release or waiver

(or otherwise releasing) our rights,

without obtaining our written

permission.

◼ You will not compromise, settle,

surrender, or release any claim or right

of recovery described above, without

obtaining our written permission.

◼ If payment is received from the other

party or parties, you must reimburse us

to the extent of benefit payments made

under this group health plan.

◼ In the event you or your attorney receive

any funds in compensation for your

illness or injury, you or your attorney

will hold those funds (up to and

including the amount of benefits paid

under this group health plan in

connection with the illness or injury) in

trust for the benefit of this group health

plan as trustee(s) for us until the extent

General Provisions


of our right to reimbursement or

subrogation has been resolved.

◼ In the event you invoke your rights of

recovery against a third-party related to

the illness or injury, you will not seek an

advancement of costs or fees from us.

◼ The amount of our subrogation interest

shall be paid first from any funds

recovered on your behalf from any

source, without regard to whether you

have been made whole or fully

compensated for your losses, and the

“make whole” rule is specifically rejected

and inapplicable under this group health

plan.

◼ We will not be liable for payment of any

share of attorneys’ fees or other

expenses incurred in obtaining any

recovery, except as expressly agreed in

writing, and the “common fund” rule is

specifically rejected and inapplicable

under this group health plan.

It is further agreed that in the event that you

fail to take the necessary legal action to

recover from the responsible party, we shall

have the option to do so and may proceed in

its name or your name against the

responsible party and shall be entitled to the

recovery of the amount of benefits paid

under this group health plan and shall be

entitled to recover its expenses, including

reasonable attorney fees and costs, incurred

for such recovery.

In the event we deem it necessary to

institute legal action against you if you fail

to repay us as required in this group health

plan, you shall be liable for the amount of

such payments made by us as well as all of

our costs of collection, including reasonable

attorney fees and costs.

You hereby authorize the deduction of any

excess benefit received or benefits that

should not have been paid, from any present

or future compensation payments.

You and your covered family member(s)

must notify us if you have the potential right

to receive payment from someone else. You

must cooperate with us to ensure that our

rights to subrogation are protected.

Our right of subrogation and

reimbursement under this group health

plan applies to all rights of recovery, and not

only to your right to compensation for

medical expenses. A settlement or judgment

structured in any manner not to include

medical expenses, or an action brought by

you or on your behalf which fails to state a

claim for recovery of medical expenses, shall

not defeat our rights of subrogation and

reimbursement if there is any recovery on

your claim.

We reserve the right to offset any amounts

owed to us against any future claim

payments.

Workers’ Compensation If you have received benefits under this

group health plan for an injury or condition

that is the subject or basis of a workers’

compensation claim (whether litigated or

not), we are entitled to reimbursement to

the extent benefits are paid under this plan

in the event that your claim is accepted or

adjudged to be covered under workers’

compensation.

Furthermore, we are entitled to

reimbursement from you to the full extent

of benefits paid out of any proceeds you

receive from any workers’ compensation

claim, regardless of whether you have been

made whole or fully compensated for your

losses, regardless of whether the proceeds

represent a compromise or disputed

settlement, and regardless of any

characterization of the settlement proceeds

by the parties to the settlement. We will not

be liable for any attorney’s fees or other

expenses incurred in obtaining any proceeds

for any workers’ compensation claim.

We utilize industry standard methods to

identify claims that may be work-related.

This may result in initial payment of some

claims that are work-related. We reserve the

right to seek reimbursement of any such

General Provisions


claim or to waive reimbursement of any

claim, at our discretion.

Payment in Error If for any reason we make payment in error,

we may recover the amount we paid.

If we determine we did not make full

payment, Wellmark will make the correct

payment without interest.

Notice If a specific address has not been provided

elsewhere in this coverage manual, you may

send any notice to Wellmark’s home office:


1331 Grand Avenue


Any notice from Wellmark to you is

acceptable when sent to your address as it

appears on Wellmark’s records or the

address of the group through which you are

enrolled.

Inspection of Coverage

Except for groups that maintain a cafeteria

plan pursuant to Section 125 of the Internal

Revenue Code (26 USCA § 125), a member

may, if evidence of coverage is not

satisfactory for any reason, return the

evidence of coverage within 10 days of its

receipt and receive full refund of the deposit

paid, if any. This right will not act as a cure

for misleading or deceptive advertising or

marketing methods, nor may it be exercised

if the member utilizes the services of the

HMO within the 10-day period. Members in

cafeteria plans must adhere to the plan

provisions concerning termination or

changes in coverage.

Submitting a Complaint If you are dissatisfied or have a complaint

regarding our products or services, call the


We will attempt to resolve the issue in a

timely manner. You may also contact

Customer Service for information on where

to send a written complaint.

Consent to Telephone Calls and Text or Email Notifications By enrolling in this employer sponsored

group health plan, and providing your

phone number and email address to your

employer or to Wellmark, you give express

consent to Wellmark to contact you using

the email address or residential or cellular

telephone number provided via live or pre-

recorded voice call, or text message

notification or email notification. Wellmark

may contact you for purposes of providing

important information about your plan and

benefits, or to offer additional products and

services related to your Wellmark plan. You

may revoke this consent by following

instructions given to you in the email, text

or call notifications, or by telling the

Wellmark representative that you no longer

want to receive calls.

Form Number: Wellmark IA Grp/GL_ 0121 105 WEB T94

Glossary

The definitions in this section are terms that are used in various sections of this coverage

manual. A term that appears in only one section is defined in that section.

Accidental Injury. An injury,

independent of disease or bodily infirmity

or any other cause, that happens by chance

and requires immediate medical attention.

Admission. Formal acceptance as a

patient to a hospital or other covered health

care facility for a health condition.

Amount Charged. The amount that a

provider bills for a service or supply or the

retail price that a pharmacy charges for a

prescription drug, whether or not it is

covered under this group health plan.

Benefits. Medically necessary services or

supplies that qualify for payment under this

group health plan.

Blue Distinction Center. A facility that

contracts with the Blue Cross Blue Shield

Association to perform specific types of

services or procedures.

BlueCard Program. The Blue Cross Blue

Shield Association program that permits

members of any Blue Cross or Blue Shield

Plan to have access to emergency care or

accidental injury services similar to those

that members have in the Wellmark Blue

HMO network.

Compounded Drugs. Compounded

prescription drugs are produced by

combining, mixing, or altering ingredients

by a pharmacist to create an alternate

strength or dosage form tailored to the

specialized medical needs of an individual

patient when an FDA-approved drug is

unavailable or a licensed health care

provider decides that an FDA-approved

drug is not appropriate for a patient’s

medical needs.

Creditable Coverage. Any of the

following categories of coverage:

◼ Group health plan (including

government and church plans).

◼ Health insurance coverage (including

group, individual, and short-term

limited duration coverage).

◼ Medicare (Part A or B of Title XVIII of

the Social Security Act).

◼ Medicaid (Title XIX of the Social

Security Act).

◼ Medical care for members and certain

former members of the uniformed

services, and for their dependents

(Chapter 55 of Title 10, United States

Code).

◼ A medical care program of the Indian

Health Service or of a tribal

organization.

◼ A state health benefits risk pool.

◼ Federal Employee Health Benefit Plan (a

health plan offered under Chapter 89 of

Title 5, United States Code).

◼ A State Children’s Health Insurance

Program (S-CHIP).

◼ A public health plan as defined in

federal regulations (including health

coverage provided under a plan

established or maintained by a foreign

country or political subdivision).

◼ A health benefits plan under Section

5(e) of the Peace Corps Act.

◼ An organized delivery system licensed

by the director of public health.

Domestic Partner. An unmarried person

who has signed the Certification of

Domestic Partnership form with the plan

member.

Domestic Provider. A facility or

practitioner that participates directly with

your employer’s domestic provider network

and also participates with the Wellmark

Blue HMO network. This is a provider that

participates with UI Health Care, University

of Iowa Hospitals and Clinics, The Iowa

Glossary

WEB T94 106 Form Number: Wellmark IA Grp/GL_ 0121

Clinic, and the Washington County Hospital

and Clinics.

Extended Home Skilled Nursing.

Home skilled nursing care, other than

short-term home skilled nursing, provided

in the home by a registered (R.N.) or

licensed practical nurse (L.P.N.) who is

associated with an agency accredited by the

Joint Commission for Accreditation of

Health Care Organizations (JCAHO) or a

Medicare-certified agency that is ordered by

a physician and consists of four or more

hours per day of continuous nursing care

that requires the technical proficiency and

knowledge of an R.N. or L.P.N.

Group. Those plan members who share a

common relationship, such as employment

or membership.

Habilitative Services. Health care

services that help a person keep, learn, or

improve skills and functioning for daily

living. Examples include therapy for a child

who isn’t walking or talking at the expected

age. These services may include physical

and occupational therapy, speech-language

pathology and other services for people with

disabilities in a variety of inpatient and/or

outpatient settings.

Illness or Injury. Any bodily disorder,

bodily injury, disease, or mental health

condition, including pregnancy and

complications of pregnancy.

Inpatient. Services received, or a person

receiving services, while admitted to a

health care facility for at least an overnight

stay.

Medical Appliance. A device or

mechanism designed to support or restrain

part of the body (such as a splint, bandage

or brace); to measure functioning or

physical condition of the body (such as

glucometers or devices to measure blood

pressure); or to administer drugs (such as

syringes).

Medically Urgent. A situation where a

longer, non-urgent response time could

seriously jeopardize the life or health of the

plan member seeking services or, in the

opinion of a physician with knowledge of

the member’s medical condition, would

subject the member to severe pain that

cannot be managed without the services in

question.

Medicare. The federal government health

insurance program established under Title

XVIII of the Social Security Act for people

age 65 and older and for individuals of any

age entitled to monthly disability benefits

under Social Security or the Railroad

Retirement Program. It is also for those

with chronic renal disease who require

hemodialysis or kidney transplant.

Member. A person covered under this

group health plan.

Nonparticipating Pharmacy. A

pharmacy that does not participate with the

network used by your prescription drug

benefits.

Office. An office setting is the room or

rooms in which the practitioner or staff

provide patient care.

Out-of-Network Provider. A facility or

practitioner that does not participate with

either the Wellmark Blue HMO network or a

Blue Cross or Blue Shield Plan in any other

state. Pharmacies that do not contract with

our pharmacy benefits manager are

considered Out-of-Network Providers.

Outpatient. Services received, or a person

receiving services, in the outpatient

department of a hospital, an ambulatory

surgery center, or the home.

Participating Pharmacy. A pharmacy

that participates with the network used by

your prescription drug benefits. Pharmacies

that do not contract with our pharmacy

benefits manager are considered Out-of-

Network Providers.

Participating Providers. These

providers participate with a Blue Cross

and/or Blue Shield Plan, but not with the


Glossary

Form Number: Wellmark IA Grp/GL_ 0121 107 WEB T94

Plan Member. The person who signed for


Plan Year. A date used for purposes of

determining compliance with federal

legislation.

Services or Supplies. Any services,

supplies, treatments, devices, or drugs, as

applicable in the context of this coverage

manual, that may be used to diagnose or

treat a medical condition.

Specialty Drugs. Drugs that are typically

used for treating or managing chronic

illnesses. These drugs are subject to

restricted distribution by the U.S. Food and

Drug Administration or require special

handling, provider coordination, or patient

education that may not be provided by a

retail pharmacy. Some specialty drugs may

be taken orally, but others may require

administration by injection or inhalation.

Spouse. A man or woman lawfully married

to a covered member.

Urgent Care Centers are classified by us

as such in Iowa if they provide medical care

without an appointment during all hours of

operation to walk-in patients of all ages who

are ill or injured and require immediate care

but may not require the services of a

hospital emergency room. For a list of Iowa

facilities classified by Wellmark as Urgent

Care Centers, please see the Wellmark

Provider Directory.

We, Our, Us. Wellmark Health Plan of

Iowa, Inc.

Wellmark Blue HMO Provider. A

facility or practitioner that participates with


X-ray and Lab Services. Tests,

screenings, imagings, and evaluation

procedures identified in the American

Medical Association's Current Procedural

Terminology (CPT) manual, Standard

Edition, under Radiology Guidelines and

Pathology and Laboratory Guidelines.

You, Your. The plan member and family

members eligible for coverage under this

group health plan.

109 WEB T94

Index

A

abuse of drugs .................................................... 36

accidental injury ................................................ 20

acupressure ......................................................... 17

acupuncture .................................................. 13, 17

addiction ....................................................... 14, 19

administrative physicals ..................................... 31

administrative services ........................... 14, 27, 41

admissions ................................................... 55, 56

adoption ....................................................... 69, 73

advanced registered nurse practitioners ..... 15, 29

allergy services .............................................. 13, 17

ambulance services ....................................... 13, 17

ambulatory facility ............................................. 24

ambulatory facility services ............................... 20

amount charged ........................................... 63, 66

anesthesia ................................................13, 18, 20

annulment .......................................................... 73

antigen therapy ............................................ 30, 36

appeals .......................................................... 55, 89

applied behavior analysis ................................... 18

arbitration .............................................. 93, 94, 95

arbitration fees ................................................... 95

assignment of benefits .............................. 101, 102

audiologists ................................................... 15, 29

authority to terminate or amend ...................... 97

authorized representative ................................. 98

autism ............................................................ 13, 18

B

benefit coordination .......................................... 83

benefit year.................................................... 61, 65

benefit year deductible ........................................ 6

benefits maximums ........................................ 9, 13

bereavement counseling .................................... 20

biological products ............................................ 29

blood .............................................................. 13, 19

Blue Distinction Center ............................... 34, 46

BlueCard program ....................................... 46, 62

bone marrow transplants .................................. 33

braces ..................................................... 23, 26, 32

brain injuries ...................................................... 59

brand name drugs .............................................. 66

breast reconstruction ......................................... 32

C

capitation ............................................................ 64

care coordination ............................................... 55

case management ............................................... 58

changes of coverage...................................... 73, 74

chemical dependency ................................... 14, 19

chemical dependency treatment facility ........... 24

chemotherapy ............................................... 14, 19

child support order ............................................ 70

children ............................................ 69, 70, 73, 85

chiropractic services ..................................... 14, 27

chiropractors ................................................ 15, 29

claim filing .................................................... 79, 83

claim forms ......................................................... 79

claim payment ................................................... 80

claims .................................................................. 79

claims excluded by applicable law ..................... 95

class actions waiver ............................................ 93

clinical trials ................................................. 14, 19

COBRA coverage .......................................... 73, 75

coinsurance ........................................ 5, 6, 8, 11, 61

communication disorders .................................. 27

community mental health center ...................... 24

complaints ........................................................ 105

complications ..................................................... 41

compounded drugs............................................. 36

concurrent review............................................... 58

conditions of coverage ....................................... 39

confidentiality..................................................... 95

contact lenses ..................................................... 34

contraceptive devices ......................................... 36

contraceptives............................................... 14, 19

contract ............................................................... 97

contract amendment .......................................... 97

contract interpretation ............................... 97, 102

convenience items ........................................ 14, 26

Index

WEB T94 110

convenience packaging ...................................... 36

conversion therapy ....................................... 14, 19

coordination of benefits .................................... 83

coordination of care ........................................... 55

copayment ............................................................ 6

cosmetic drugs ................................................... 36

cosmetic services .......................................... 14, 19

cosmetic surgery ........................................... 15, 32

counseling .................................................... 14, 20

coverage changes ................................... 73, 74, 97

coverage continuation ..................................75, 76

coverage effective date....................................... 69

coverage eligibility ....................................... 69, 73

coverage termination .................................... 74, 75

covered claims.................................................... 93

creditable coverage ............................................ 73

custodial care ..................................................... 23

cystic fibrosis...................................................... 59

D

damaged drugs ................................................... 36

death ................................................................... 73

deductible ............................................................. 6

deductible amounts ............................................. 4

degenerative muscle disorders.......................... 59

dental services .............................................. 14, 20

dependents ....................................... 69, 70, 73, 85

DESI drugs ......................................................... 29

diabetes ......................................................... 14, 21

diabetic education......................................... 14, 21

diabetic supplies ................................................ 26

dialysis ........................................................... 14, 21

dietary products ................................15, 20, 27, 37

disabled dependents .......................................... 69

divorce ................................................................ 73

doctors ........................................................... 15, 29

doctors of osteopathy ................................... 15, 29

domestic partners .............................................. 69

drug abuse ............................................... 14, 19, 36

drug prior authorization .................................... 59

drug quantities ............................................. 37, 66

drug rebates ................................................. 64, 67

drug refills .......................................................... 37

drug tiers ............................................................ 65

drugs ................................................. 15, 29, 34, 65

drugs that are not FDA-approved .............. 30, 36

E

education ...................................................... 14, 20

effective date ....................................................... 69

eligibility for coverage .................................. 69, 73

emergency room copayment ........................... 4, 7

emergency services ................................. 14, 21, 50

EOB (explanation of benefits) .......................... 80

exclusions .................................................... 39, 40

expedited external review .................................. 91

experimental services ........................................ 40

explanation of benefits (EOB) .......................... 80

eye services ................................................... 16, 34

eyeglasses ............................................................ 34

F

facilities ......................................................... 14, 24

family counseling .............................................. 20

family deductible .................................................. 6

family member as provider ................................ 41

FDA-approved A-rated generic drug ................ 66

fertility services ............................................ 14, 22

filing claims .................................................. 79, 83

foot care (routine) .............................................. 25

foot doctors ................................................... 15, 29

foreign countries .......................................... 37, 48

foster children .............................................. 69, 73

fraud .................................................................... 75

G

gamete intrafallopian transfer ........................... 22

generic drugs ...................................................... 66

genetic testing ............................................... 14, 22

GIFT (gamete intrafallopian transfer) .............. 22

government programs .................................. 41, 83

guest membership .............................................. 50

gynecological examinations .......................... 15, 31

H

hairpieces ...................................................... 16, 34

hearing services ............................................ 14, 22

hemophilia .......................................................... 59

high risk pregnancy ............................................ 59

home health services .................................... 14, 22

home infusion therapy ...................................... 30

Index

111 WEB T94

home office (Wellmark) .................................. 105

home/durable medical equipment ..............14, 23

hospice respite care ........................................... 24

hospice services ........................................... 14, 24

hospital services ........................................... 20, 75

hospitals ....................................................... 14, 24

I

ID card .................................................... 45, 46, 52

illness ............................................................. 14, 25

impacted teeth ................................................... 20

in vitro fertilization ............................................ 22

infertility drugs .................................................. 37

infertility treatment ..................................... 14, 22

information disclosure ...................................... 98

infused drugs ..................................................... 37

inhalation therapy ................................. 14, 23, 25

injury ............................................................. 14, 25

inpatient facility admission ......................... 55, 56

inpatient services .......................................... 61, 75

inspection of coverage ..................................... 105

insulin ................................................................. 30

investigational or experimental drugs .............. 36

investigational services ..................................... 40

irrigation solutions and supplies ...................... 37

K

kidney dialysis ..................................................... 21

L

L.P.N. .................................................................. 23

laboratory services ....................................... 16, 34

late enrollees ...................................................... 69

licensed independent social workers ........... 15, 29

licensed practical nurses ................................... 23

lifetime benefits maximum ............................... 42

limitations of coverage ................ 9, 13, 39, 42, 66

lodging .......................................................... 16, 34

long term acute care facility .............................. 25

long term acute care services ............................ 25

lost or stolen items ............................................ 36

M

mail order drug program ................................... 52

mail order drugs ................................................ 52

mammogram (3D) .............................................. 31

mammograms ............................................... 15, 31

marriage .............................................................. 73

marriage counseling .......................................... 20

massage therapy ................................................. 27

mastectomy......................................................... 32

maternity services ........................................ 14, 25

maximum allowable fee .............................. 63, 66

medicaid enrollment ........................................ 102

medicaid reimbursement ................................. 102

medical doctors ............................................ 15, 29

medical equipment ................................. 14, 23, 37

medical evacuation ....................................... 14, 26

medical supplies ........................................... 14, 26

medical support order ........................................ 70

medically necessary ............................................ 39

Medicare ....................................................... 73, 83

medication therapy management ...............30, 37

medicines .......................................... 15, 29, 34, 65

mental health services.................................. 14, 27

mental health treatment facility ........................ 24

mental illness ................................................ 14, 27

military service ................................................... 41

misrepresentation of material facts .................. 75

motor vehicles .............................................. 14, 27

muscle disorders ................................................ 59

musculoskeletal treatment .......................... 14, 27

N

network providers ........................................ 45, 63

network savings .................................................. 63

newborn children ............................................... 73

nicotine dependence .......................................... 31

nicotine dependency drugs ................................ 36

nonassignment of benefits ............................... 101

nonmedical services ............................... 14, 27, 41

nonparticipating pharmacies ...................... 51, 67

notice ................................................................. 105

notification of change ........................................ 74

notification requirements .................................. 55

nursing facilities ........................................... 24, 75

nutrition education ...................................... 14, 21

nutritional products ............................... 15, 20, 27

O

occupational therapists ................................ 15, 29

Index

WEB T94 112

occupational therapy ............................. 15, 23, 28

office visit copayment ...................................... 4, 7

optometrists .................................................. 15, 29

oral contraceptives ............................................. 19

oral surgeons ................................................. 15, 29

organ transplants ..........................................16, 33

orthotics (foot) ............................................. 15, 28

osteopathic doctors ....................................... 15, 29

other insurance ............................................ 41, 83

out-of-area coverage .............................. 37, 46, 62

out-of-network providers .................................. 63

out-of-pocket maximum ........................ 5, 6, 8, 11

oxygen .......................................................... 23, 26

P

packaging ........................................................... 36

Pap smears .................................................... 15, 31

participating pharmacies ............................. 51, 67

participating providers ................................ 45, 62

payment arrangements ............................... 63, 67

payment in error .............................................. 105

payment obligations 4, 8, 9, 12, 39, 43, 52, 61, 65, 67

personal items .............................................. 14, 26

physical examinations .................................. 15, 31

physical therapists ........................................ 15, 29

physical therapy ..................................... 15, 23, 28

physician assistants ...................................... 15, 29

physicians ...................................................... 15, 29

plan year ............................................................. 97

plastic surgery ............................................... 14, 19

platelet-rich plasma injections.......................... 29

podiatrists ..................................................... 15, 29

practitioners .................................................. 15, 29

precertification............................................. 42, 55

pregnancy ........................................................... 25

pregnancy (high risk) ........................................ 59

prenatal services ................................................ 25

prescription drugs ..................... 15, 29, 34, 65, 66

preventive care ............................................. 15, 30

preventive items ................................................ 35

preventive services............................................. 35

prior approval .............................................. 42, 57

prior authorization ...................................... 42, 59

privacy ................................................................ 98

pronuclear stage transfer (PROST) ................... 22

prosthetic devices ................................... 15, 23, 32

provider network ......................................3, 45, 62

provider types ....................................................... 3

psychiatric medical institution for children (PMIC) ............................................................ 24

psychiatric services ............................................ 27

psychologists ................................................ 15, 29

public employees ................................................ 75

pulmonary therapy ................................. 14, 23, 25

Q

qualified medical child support order ............... 70

quantity limits .............................................. 37, 66

R

R.N. ................................................... 15, 23, 25, 29

radiation therapy .......................................... 14, 19

rebates ........................................................... 64, 67

reconstructive surgery ................................. 15, 32

referrals ............................................................... 46

refills ................................................................... 37

registered nurses .............................. 15, 23, 25, 29

reimbursement of benefits....................... 102, 105

release of information ....................................... 98

removal from coverage ...................................... 73

repatriation ................................................... 15, 32

residential treatment facility ............................. 24

respiratory therapy................................. 14, 23, 25

rights of appeal .................................................. 89

routine services ............................................ 15, 30

S

self-help ........................................................ 15, 32

separation ........................................................... 73

service area ......................................................... 46

short-term home skilled nursing ....................... 23

skilled nursing services ...................................... 23

sleep apnea ................................................... 15, 32

social adjustment ......................................... 15, 32

social workers ............................................... 15, 29

specialty drugs ....................................... 30, 36, 52

speech and hearing practitioners at Wendell Johnson Clinic ............................................... 15

speech pathologists ...................................... 15, 29

speech therapy .............................................. 15, 33

Index

113 WEB T94

spinal cord injuries ............................................ 59

spouses ......................................................... 69, 73

stepchildren ....................................................... 69

students ........................................................ 69, 73

subrogation ...................................................... 102

surgery ........................................................... 15, 33

surgical facility ................................................... 24

surgical facility services ..................................... 20

surgical supplies .......................................... 14, 26

survival and severability of terms ..................... 95

T

take-home drugs .......................................... 30, 35

telehealth ....................................................... 15, 33

telehealth services copayment ......................... 5, 7

temporomandibular joint disorder ..............16, 33

termination of coverage ............................... 74, 75

therapeutic devices ............................................ 37

third party liability .............................................. 41

TMD (temporomandibular joint disorder) .16, 33

tooth removal ..................................................... 20

transplants .............................................. 16, 33, 59

travel ............................................................. 16, 34

tubal ligation ....................................................... 22

U

urgent care center copayment ......................... 5, 8

V

vaccines ............................................................... 29

vasectomy ........................................................... 22

vehicles ......................................................... 14, 27

vision services ............................................... 16, 34

W

weight reduction drugs ...................................... 37

well-child care ............................................... 15, 31

Wellmark drug list ............................................. 65

wigs ............................................................... 16, 34

workers’ compensation .............................. 41, 104

X

x-rays............................................................. 16, 34

114 WEB T94


Customer Service: 800-355-2031

Cedar Rapids 52401-1610

600 3rd Avenue SE, Suite 200

Des Moines 50306-9232

Main Office

1331 Grand Avenue

P.O. Box 9232

Sioux City 51102-1677

Hamilton Boulevard & I-29

P.O. Box 1677

The University of Iowa Benefits Office

120 University Services Bldg.

Iowa City, Iowa 52242-1911

319-335-2676

877-830-4001 toll free

Required Federal Accessibility and Nondiscrimination Notice

Discrimination is against the lawWellmark complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Wellmark does not exclude people or treat them differently because of their race, color, national origin, age, disability or sex.

Wellmark provides:• Free aids and services to people with disabilities so they may

communicate effectively with us, such as:• Qualified sign language interpreters• Written information in other formats (large print, audio,

accessible electronic formats, other formats)• Free language services to people whose primary language is

not English, such as:• Qualified interpreters• Information written in other languages

If you need these services, call 800-524-9242.

If you believe that Wellmark has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: Wellmark Civil Rights Coordinator, 1331 Grand Avenue, Station 5W189, Des Moines, IA 50309-2901, 515-376-4500, TTY 888-781-4262, Fax 515-376-9073, Email [email protected]. You can file a grievance in person, by mail, fax or email. If you need help filing a grievance, the Wellmark Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail, phone or fax at: U.S. Department of Health and Human Services, 200 Independence Avenue S.W., Room 509F, HHH Building, Washington DC 20201, 800-368-1019, 800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ATENCIÓN: Si habla español, los servicios de asistencia de idiomas se encuentran disponibles gratuitamente para usted. Comuníquese al 800-524-9242 o al (TTY: 888-781-4262).

注意：如果您说普通话，我们可免费为您提供语言协助服务。请拨打 800-524-9242 或（听障专线： 888-781-4262）。

CHÚ Ý: Nếu quý vị nói tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ miễn phí có sẵn cho quý vị. Xin hãy liên hệ 800-524-9242 hoặc (TTY: 888-781-4262).

NAPOMENA: Ako govorite hrvatski, dostupna Vam je besplatna podrška na Vašem jeziku. Kontaktirajte 800-524-9242 ili (tekstualni telefon za osobe oštećena sluha: 888-781-4262).

ACHTUNG: Wenn Sie deutsch sprechen, stehen Ihnen kostenlose sprachliche Assistenzdienste zur Verfügung. Rufnummer: 800-524-9242 oder (TTY: 888-781-4262).

تنبيه: إذا كنت تتحدث اللغة العربية, فإننا نوفر لك خدمات المساعدة اللغوية، المجانية. اتصل بالرقم9242-524-800 أو (خدمة الهاتف النصي: 888-781-4262).

ສິ່ ງຄວນເອົາໃຈໃສ,່ ພາສາລາວ ຖາ້ທາ່ນເວ້ົາ: ພວກເຮົາມບໍີລກິານຄວາມຊວ່ຍເຫືຼອດາ້ນພາສາໃຫທ້າ່ນໂດຍບ່ໍເສຍຄາ່ ຫືຼ 800-524-9242 ຕດິຕ່ໍທ່ີ. (TTY: 888-781-4262.)

주의: 한국어 를 사용하시는 경우, 무료 언어 지원 서비스를 이용하실 수 있습니다. 800-524-9242번 또는 (TTY: 888-781-4262)번으로 연락해 주십시오.

ध्यान रखें : अगर आपकी भयाषया हिन्दी ि,ै तो आपके हिए भयाषया सिया्तया सवेयाएँ, हनःशुलक उपिब्ध िैं। 800-524-9242 पर सपंक्क करें ्या (TTY: 888-781-4262)।

ATTENTION : si vous parlez français, des services d’assistance dans votre langue sont à votre disposition gratuitement. Appelez le 800 524 9242 (ou la ligne ATS au 888 781 4262).

Geb Acht: Wann du Deitsch schwetze duscht, kannscht du Hilf in dei eegni Schprooch koschdefrei griege. Ruf 800-524-9242 odder (TTY: 888-781-4262) uff.

โปรดทราบ: หากคุณพูด ไทย เรามีบริการช่วยเหลือด้านภาษาสำาหรับคุณโดยไม่คิดค่าใช้จ่าย ติดต่อ 800-524-9242 หรือ (TTY: 888-781-4262)

PAG-UKULAN NG PANSIN: Kung Tagalog ang wikang ginagamit mo, may makukuha kang mga serbisyong tulong sa wika na walang bayad. Makipag-ugnayan sa 800-524-9242 o (TTY: 888-781-4262).

w>'k;oh.ng= erh>uwdR unDusdm< usdmw>rRpXRw>zH;w>rRwz.< vXwb.vXmbl;vJ< td.vXe*D>vDRI qJ;usd;ql

800=524=9242 rhwrh> (TTY: 888=781=4262) wuh>I

ВНИМАНИЕ! Если ваш родной язык русский, вам могут быть предоставлены бесплатные переводческие услуги. Обращайтесь 800-524-9242 (телетайп: 888-781-4262).

सयाव्धयान: ्द् तपयाईं नपेयािदी बोलनहुुन्छ भन,े तपयाईंकया ियाहग हन:शलुक रूपमया भयाषया सिया्तया सवेयािरू उपिब्ध गरयाइन्छ । 800-524-9242 वया (TTY: 888-781-4262) मया समपक्क गनु्किोस ्।

ማሳሰቢያ፦ አማርኛ የሚናገሩ ከሆነ፣ የቋንቋ እገዛ አገልግሎቶች፣ ከክፍያ ነፃ፣ ያገኛሉ። በ 800-524-9242 ወይም (በTTY: 888-781-4262) ደውለው ያነጋግሩን።

HEETINA To a wolwa Fulfulde laabi walliinde dow wolde, naa e njobdi, ene ngoodi ngam maaɗa. Heɓir 800-524-9242 malla (TTY: 888-781-4262).

FUULEFFANNAA: Yo isin Oromiffaa, kan dubbattan taatan, tajaajiloonni gargaarsa afaanii, kaffaltii malee, isiniif ni jiru. 800-524-9242 yookin (TTY: 888-781-4262) quunnamaa.

УВАГА! Якщо ви розмовляєте українською мовою, для вас доступні безкоштовні послуги мовної підтримки. Зателефонуйте за номером 800-524-9242 або (телетайп: 888-781-4262).

Ge’: Diné k’ehj7 y1n7[ti’go n7k1 bizaad bee 1k1’ adoowo[, t’11 jiik’4, n1h0l=. Koj8’ h0lne’ 800-524-9242 doodaii’ (TTY: 888-781-4262)

Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Health Plan of Iowa, Inc., Wellmark Synergy Health, Inc., Wellmark Value Health Plan, Inc. and Wellmark Blue Cross and Blue Shield of South Dakota are independent licensees of the Blue Cross and Blue Shield Association.

M-2318376 09/16 A

mailto:CRC%40Wellmark.com?subject=

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html

http://www.hhs.gov/ocr/office/file/index.html

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